Personality disorders in older adults: diagnosis and management
Personality disorder traits can be quite problematic in older adult patients and the effects of these traits can sometimes present as risks that the professionals working in this field must be confident in managing. It is therefore crucial that information around the presentation and management of these disorders in the older adult psychiatry patient cohort is available. Here, the authors summarise current knowledge regarding the assessment and management of personality disorders in the older adult population, based on a literature search.
The diagnosis of personality disorder relates to pervasive disturbances within an individual’s personality and behaviour, which can often go on to have a detrimental effect on their social functioning and relationships. These disorders can have a significant impact on a person’s life, including their ability to respond to life stresses. It is well known that the care of patients with personality disorders makes up a large proportion of the work of general adult psychiatrists, largely due to the presence of impulsivity and self-harming behaviours that are frequently present.1 Emotionally unstable (impulsive or borderline) personality disorder in particular is common and is associated with repeated self-injurious and suicidal behaviours.1,2
It has long been felt in older adult psychiatric settings that these diagnoses are not applicable to this patient population as they ‘age out’. The maturation of psychological defences over a lifetime will also tend to attenuate the impulsivity and aid with the management of life stresses, which can be significant in this age group. The reduction of this impulsive behaviour should also, therefore, reduce the self-harming behaviours in this cohort.3,4 From experience in the clinical setting it is safe to say that personality disorder traits can actually still be quite problematic in older adult patients and that the effects of these traits can sometimes present as risks that the professionals working in this field must be confident in managing. It is therefore crucial that information around the presentation and management of these disorders in the older adult psychiatry patient cohort is available.
Literature search criteria
A literature search was completed via the NHS Search System ‘Healthcare Database Advanced Search,’ which includes AMED, EMBASE, HMIC, BNI, Medline, Psychinfo, CINAHL and Health Business Elite. The keywords used were: ‘personality disorder’; ‘emotionally unstable personality disorder’; ‘borderline personality disorder’; ‘older adult’, and ‘old age’.
Results (all English abstracts and full texts, where available) were reviewed to ascertain relevance. Manual review was undertaken, initially by the first author and checked by the second author, to identify common themes and areas that could further aid our understanding. Results included literature reviews and opinion pieces, book chapters, observational studies, case reports and also a case-control study. Once duplicates were removed, 109 articles were reviewed and any relevant information was extracted. 13 further articles were excluded due to lack to relevance to the aims of the review or demonstrating merely responses to previous articles. (Table 1) It is worth noting from the outset that it has already been recognised that the literature available about personality disorders in older adults is both less than that available in the general adult cohort and also less than that available about other diagnoses within this same cohort.5
Relevance of personality disorders in older adults
The prevalence of personality disorders in the older adult population has been estimated to be around 10% and of course, with the ageing population, this figure must be expected to continue to rise.6,7,8 The authors therefore expect that the management of patients with personality disorders will make up a significant proportion of the clinical workload of psychiatrists managing older patients. It is generally felt that, rather than presenting de novo in older adults, the relatively mild personality dysfunctions in the younger cohort, which may have not previously presented as problematic and have therefore remained under the radar of secondary mental health services, may actually worsen and re-emerge in the older adult population.6 Age is not felt to lessen the effects of childhood adversity and stressful life events on mental disorders, which are factors that are known to be frequently present in patients with personality disorders.9,10 It may even be the case that the self-harming and suicidal behaviours associated with some personality disorders present as a response to the new stresses that can be faced in older age, when the coping skills and social support may be lacking.4 Personality disorders are therefore diagnoses that should not be discounted in the older adult age group.
Clinical presentation of personality disorders in older adults
Both recognising and effectively managing the difficulties associated with personality disorders in older adults is crucially important as personality disorder dimensions have been found to explain the majority of the variance in suicidal ideation amongst older adults.11 This may be partially explained by the finding that older adults with personality disorders, particularly if multiple, tend to have a worse self-perceived quality of life than others within their cohort, including those who may also be known to secondary mental health services themselves.12 Suicidal ideation itself has been found to be one of the best predictors of completed suicide in this population and it has been hypothesised that maladaptive coping, which is often seen as a feature in personality disorders, significantly predicts this risk also.13 The association between borderline personality disorder specifically and the risk of suicide has been well documented and this is the case particularly when comorbid with major depressive disorder, which is common in this age group.2,14–17 In older adult patients who do go on to complete suicide successfully, it has been found that the majority (77%) had a known underlying mental health condition, with personality disorders making up a very significant proportion (44%).18 It is therefore apparent that a failure to identify these diagnoses could be catastrophic. However, difficulties can arise in correctly making the diagnosis in this cohort, as will be described.
As has been experienced by the authors, the presentation of personality disorders in older adult patients can differ from that which professionals have become more familiar with when treating patients in the younger age group. This can create difficulty and uncertainty when diagnoses are being considered and, furthermore, it has been found that the majority of psychological tests currently available are wholly unreliable in this age group.19 It is therefore of great importance that there is an awareness of these differences and that those involved in the care of older adults have as much information as possible that can aid in their assessments. The more objective and observable behaviours associated with personality disorders, such as impulsivity and aggression, are often seen to decline in intensity and frequency with age. Despite this, the underlying affective and identity disturbances together with the interpersonal difficulties, are not found to decline.6,20 The symptoms associated with personality disorders can therefore, whilst not being as readily observable, continue to be a source of significant distress in the older adult patient cohort. Together with this often less ‘dramatic’ presentation, it can also be difficult to ascertain whether the functional impairment, which may be part of the clinical picture is due to an underlying personality disorder or due to the physiological effects of ageing in general.7
Additionally, it is important to be aware that the personality traits present in the older adult population are the result of numerous interrelated factors and it is not appropriate to simply assign them to a personality disorder diagnosis alone. These factors can include original character traits, major life events and experiences and the stresses caused by the physiological changes associated with aging.21 These primary and secondary changes can complicate the assessment and it is important to be mindful of them. Comprehensive assessment is therefore required before being able to make a diagnosis with certainty. Ageist stereotypes or a lack of appreciation of the cultural context can also have significant implications. It has been highlighted that in some cases the ‘eccentricities’ of an older adult may be misinterpreted as being part of the presentation of an underlying personality disorder.22
Diagnostic criteria and challenges in assessment of personality disorders in older adults
Secondary to the difficulties described above, it has been suggested that relying on the currently available diagnostic criteria alone to aid with diagnosis is therefore inadequate. Personality characteristics are known to change during an individual’s lifetime and assessments should therefore be adapted to take into account the various age-related factors that can impact the interpretation of clinical findings. These may, themselves, lead to a presentation felt to be part of a personality disorder.23,24 It has been suggested that diagnostic criteria may be more accurate in this population if more weight is given to the internal psychological factors, and less weight given to the more observable, ‘risky’ behavioural expressions.8 The currently available classifications appear to contain a measurement bias across the age groups as older adults are likely to endorse certain criteria that the general adult cohort may not.25 It is thought that the development of future editions of diagnostic criteria, which give adequate consideration to the evolution of personality disorders with age, and take into account the changes in behaviour and interpersonal functioning, would aid with these diagnostic difficulties.23,26,27 The diagnostic criteria may actually contain this bias to such an extent as to make them wholly inadequate for the older adult cohort.28 Furthermore, a shift away from categorical classifications and towards more dimensional measures may help, especially when the context of later life is specifically considered. Addressing the unique challenges associated with the assessment of personality disorders in older adults will help in the development of diagnostic criteria with validity, reliability and utility.29
Work has been carried out to contribute to the formulation of more reliable, updated instruments and diagnostic criteria that can aid in diagnosis of personality disorders in the older adult cohort. An instrument was constructed, and assessed, which incorporated habitual behaviours, biographical information and also the observed actual behaviours demonstrated in this group of patients. It was found that sixteen items assessed could be used successfully as a screening instrument to detect personality disorders in older adult patients. These items were named the ‘Gerontological Personality Disorder Scale’30 (see Table 2). This work was completed over 10 years ago and, as this scale is not being used currently in clinical practice, the authors can only conclude that more research around the use of assessment instruments is therefore needed before there can be any real changes or progress in this field and in clinical practice.
Even with age-appropriate diagnostic criteria, as with all psychiatric disorders, an accurate diagnosis relies heavily on the ability to gain useful information from the history. In the diagnosis of personality disorders, an ability to gain details around presentations at different periods of the life and in different situations is crucial. Assessment is therefore dependent on gaining a comprehensive and accurate lifetime history. This can present its own challenges. Older adults can often present either without a co-informant, or with a co-informant who can provide little detail about their early life. Of course, as with adults of working age, both the patient and the co-informant may provide unreliable information. Unfortunately this may be more problematic in this age group due to the presence of cognitive impairment in both the patient and the co-informant.6
It has also been found that self-reported personality disorder traits tend to show a decrease over time, whereas informant-reported traits may show an increase.31,32 It is therefore unclear what reports would be best to rely on when considering a diagnosis of personality disorder.
Management of personality disorders in older adults
Once the diagnosis of personality disorder in an older adult is made, it is important to be aware of the evidence available around effective management. Unfortunately, the management of personality disorders as a primary diagnosis in this cohort of patients is a relatively unexplored topic and there is little information available about the outcomes that one should expect. There is, however, the understanding that the mainstay of treatment is to identify and treat comorbid disorders such as depression, psychosis and dementia, which are often also present.6 It is important to note, however, that paradoxically, despite this advice, the presence of personality disorders in these patients may actually complicate the psychological treatment of other disorders due to the increase in interpersonal disturbance and emotional distress.33 The presence of a personality disorder in older adult patients with comorbid depression has been shown to negatively impact on the outcomes of treatment of the affective disorder itself. It can predict both maintenance and the re-emergence of depressive symptoms in these patients. It has been suggested that this may be related to the expression of certain known personality disorder traits, such as interpersonal rigidity, chronic hopelessness and the use of avoidance.34 In the acute treatment of depression in later life, there is an association with persistent functional impairment even once the episode has been treated.35 The presence of Cluster B personality disorders and the associated symptomatology has specifically been shown to contribute to both a decline in global functioning and in quality of life over a one year period in older adult patients following treatment for depression.36 Cluster C personality disorders on the other hand have been associated with an increased time to response in acute treatment and non-response in maintenance treatment.35 This undoubtedly creates further difficulties in providing adequate care, and further highlights the importance of not missing a diagnosis of personality disorder.
Although the mainstay of treatment should be in treating comorbidities, some psychiatrists may consider the use of pharmacological agents to aid in the symptomatic management of the affective instability and impulsive aggression associated with some personality disorders. In these cases, however, caution must be taken around the altered pharmacokinetics, pharmacodynamics and the presence of physical comorbidities in older adults.1,7 These can raise their own difficulties when psychotropic medications are being considered.
Psychological management of personality disorders in older adults
Psychological input is felt to form the mainstay of treatment in older adult patients with personality disorders. Various treatment modalities have been put forward, including supportive psychotherapy, cognitive behavioural therapy, cognitive analytic therapy, psychodynamic therapy, particularly when comorbid with depression and dialectical behaviour therapy where self-harming and dramatic impulsive behaviours predominate.
Family therapy has also been found to be useful in some.6 It has been proposed that, regardless of the specific modality, both individual and group therapy aimed at personality adaptation behaviour would be the most suitable form of psychological input.37 It is important, however, that any existing treatments that are used are adapted to take into account specific age-related factors and needs. This can include taking into account cohort beliefs and changing life perspectives, as well as the patient’s beliefs about the importance and consequences of somatic comorbidities.38
It is clear to see that there is no one consensus view around psychological treatment at this stage and further research is needed. It is also crucial to appreciate that successful psychotherapy requires an accurate diagnosis, which is something already shown to not be straightforward. Interestingly, there has been one small pilot looking into the success of therapeutic communities in managing borderline personality disorder in this age cohort. Positive outcomes, similar to those we would expect in adults of working age, were shown here.39
Key findings from the literature relating to personality disorder diagnosis and management are summarised in Table 3.
It must be highlighted that this review is limited somewhat in how much it can add, as there is currently a dearth of literature available in this field and no fixed conclusions have been formed. It is a novel topic and it is likely that knowledge will continue to grow.
It is, however, evident from the literature available that personality disorders are important diagnoses to consider even in the older adult cohort and that they are very important in the assessment of risk to self. It is pivotal for professionals working with older adults to be mindful of the differing presentations in this cohort and to therefore appreciate that the existing diagnostic criteria may not actually be fit for this purpose. Further work to allow the development of reliable and age-appropriate diagnostic criteria to aid us with these difficulties is imperative. It is also clear that more research is needed around the management of older adult patients with personality disorders, particularly in terms of psychological input. This will aid both in management and the ability to make more accurate predictions around the expected prognosis and outcomes.
Dr Mattar is a CT3 Doctor at Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) and Dr Khan is a Consultant Psychiatrist at BSMHFT and an Honorary Senior Lecturer at University of Chester
Declaration of interests
No conflicts of interest were declared.
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