Mohammed T. Abou-Saleh

AETIOLOGY AND GENETICS 589and sensory status of this aged sample, many of whom may havemisunderstood the questions or exhibited executive deficit-relatedpersonality alterations.Institutional SettingsEarly PD prevalence rates in nursing home settings were reportedto be 12–15% 36,37 , while for geropsychiatric inpatients, PDestimates were more variable (7–55%). In a large sample ofhospitalized male veterans, Molinari et al. 38 conducted a crosssectionalinvestigation of personality changes across different agegroups for those clinically diagnosed with PD. Older adults withPD were more responsible and less impulsive, paranoid, energeticand antisocial than young adults diagnosed with PD. Kunik etal. 39 studied 547 older psychiatric inpatients, and found that aconsensus case conference diagnosis of PD varied widely,depending upon the specific co-morbid Axis I diagnosis (e.g.6% for patients with an organic mental disorder, but 24% forthose with depression). Only two studies of geropsychiatricinstitutionalized patients utilized standardized instruments. Molinariet al. 40 used the SIDP-R and found that older adults had PDrates similar to those of a young adult comparison sample;however, older adults were less likely to meet criteria for morethan one PD, and clinical diagnoses yielded fewer PDs than theSIDP-R. Likewise, Coolidge et al. 41 used the Coolidge Axis IIInventory and found similarly high PD rates among young (66%)and old (58%) chronically mentally ill patients, but the youngergroup was more likely to be specifically diagnosed with antisocial,borderline, and schizotypal PD.Outpatient SettingsThe findings from the lone study conducted with a structured PDscale in a geropsychiatric outpatient setting are consistent with thelatter inpatient studies. Molinari and Marmion 42 found that olderadults were less likely to meet the criteria for more than one PDthan younger adults, and clinical diagnosis again yielded fewerPDs than the SIDP-R.range of 6–33%) for those over the age of 50, and concluded that,‘‘at this time the literature neither supports nor contradictsprevious suggestions of an age effect’’. However, these authorsremark that the bulk of the evidence supports, at least for certainPDs, a decline in frequency and intensity with age. The cause forthis decline is one of the most controversial and debated topics inthe literature on PD in older adults. Four main reasons have beenpostulated.First, there is a general mellowing of the ‘‘high-energy’’ ClusterB PDs due to biological (reduced testosterone in males) anddevelopmental changes (those with PD finally master a singleinterpersonal strategy to manage stresses). This accounts for theconsistent result that older adults are less likely to meet the criteriafor more than one PD, and is also supported by the recent studyof Segal et al. 32 , who discovered lower levels of dysfunctionalcoping styles in older adults.Second, the decline in ‘‘high-energy’’ PD relates to the greatermortality rates of those with Cluster B PD in their younger years.Older adults with PD are thereby a selective sample of lessextreme PD ‘‘survivors’’. Third, PD is generally underdiagnosed,particularly in older adults, where cognitive and medical causesare emphasized or personality disturbance (avoidance, dependency,lability) is viewed as normal 48 .Fourth, the decline in PD with age is a methodological artifact,since some DSM criteria are age-insensitive. For example,occupational and vocational impairment are often irrelevant toolder adults. From this point of view, there really is no truedecline in PD rates with age, just a change in form that isinadequately assessed. These so-called ‘‘geriatric variants’’ 49reflect the more subclinical, non-specific or age-relevant PD traitsthat account for PD NOS (not otherwise specified) to bediagnosed with particular high frequency in older adults. Theconstruction of a new geriatric nosology has been proposed toaccommodate the late life changes in Axis II pathology 46,47,49 .Such re-classification will need to: (a) reconsider the diagnosticrequirement that maladaptive PD behavior be rooted so early inyoung adulthood; (b) routinely address Axis II pathology in thecontext of more acute Axis I symptomatology; and (c) integrateage-related developmental, medical (Axis III) and psychosocial/environmental stressors (Axis IV) with Axis II manifestations 46 .DepressionOne area of intense study has been the relationship between PDand depression in older adults. Kunik et al. 24 studied 154depressed older inpatients and identified 24% with co-morbidPD, while Molinari and Marmion 43 determined that 63% ofdepressed geropsychiatric outpatients met PD criteria. Thompsonet al. 44 found that 33% of depressed older adults who were beingtreated with psychotherapy in a geropsychiatric outpatient clinicmet DSM-III PD criteria. In a study investigating the relationshipbetween PD and functioning in acutely depressed older psychiatricpatients, Axis II pathology was found to be associated withgreater disability and more impaired social and interpersonalfunctioning 45 . In their review of the literature on PD in olderadults, Agronin and Maletta 46 posit that PD in late life may beintrinsically related to Axis I pathology, particularly majordepressive disorder.Summary of Epidemiological StudiesIn an attempt to lend clarity to the burgeoning literature on PD inolder adults, Abrams and Horowitz 47 conducted a meta-analysisof the most methodologically sophisticated epidemiologicalstudies. They inferred a PD prevalence rate of 10% (with aPROGNOSISUnfortunately, only a few seemingly contradictory studies haveinvestigated the prognosis of PD in late life. In two separatestudies of geropsychiatric outpatients, PD was found to be a poorprognostic sign for the psychotherapeutic treatment of depression44,50 . However, Molinari 51 examined the 1 year relapse ratesfor 100 male geropsychiatric inpatients and found no significantdifferences for those diagnosed with and without PD. Consistentwith Kunik et al.’s 24 finding that PD diagnosis had no impact onthe acute response of inpatient treatment for depression with olderadults, no differences were found in relapse rates for a subgroupof depressed inpatients with and without PD 51 . It appears that ininpatient geropsychiatric settings, Axis I symptomatology overridesAxis II pathology as an outcome predictor, probably relatedto the complex combination of medical, cognitive and psychiatricsymptoms often observed in those older patients needing acutecare.RESEARCH IMPLICATIONSBase rates mandating prohibitively large sample sizes render itdifficult to make valid statements concerning age-related changesfor most individual PDs. To expand our current inadequate