Personality and personality disorders in the elderly: Diagnostic, course and management

Objective. - Little is known about personality and personality disorders in the elderly. This paper summarizes the literature in these fields. Methods. Articles were selected using a Medline and Google Scholar search. The keywords were personality, personality disorder, aging and elderly. Results. - Personality is not fixed and can change across the life-time including in the elderly. Personality disorders are frequent with a prevalence estimated between 10 and 20%. These rates are essentially equivalent to that of younger groups. Clinical presentation of these disorders may change overtime. Longitudinal observations generally support that the "immature" personality disorders (cluster B), show improvement over time, while the more "mature" (clusters A and C) are characterized by a more chronic course. Many patients with late onset schizophrenia or delusional disorder have a premorbid cluster A personality. Patients with cluster C personality are also stable, and exposed, like all other personality disorders, to depression. Studies suggest that personality disorders may attenuate, re-emerge or appear de novo according to the cluster and the social context. Diagnosing personality disorders in the elderly is a complex undertaking, largely because of the difficulty encountered in distinguishing functional impairments related to personality from those related to physiological and environmental aspects of aging. Tools for assessing personality disorders exist, but there is no ideal assessment instrument for geriatric personality disorders. Psychiatric history and biographical elements have to be collected accurately. Personality disorders may seriously complicate mental and physical health and quality of life. Indeed, a greater risk of depression, suicide, dementia and social isolation is shown in this population. Different types of caring and treatment exist including psychotherapy and pharmacotherapy. Pharmacological strategies should consider augmentation with psychotherapeutic strategies. Interventions should target the predominant presenting problems. Indeed, personality disordered elderly people are a heterogeneous group with frequent axis I comorbidities. Care should be taken on how to administer pharmacological treatment (risk of noncompliance or abuse), pharmacokinetics, pharmacodynamics and finally interaction with age-specific comorbidities. Psychotherapy has shown its effectiveness notably in the management of depression. In institutions, clinical identification of a personality disorder would inform and advise staff regarding the approach to be adopted, and also avoid negative countertransference, emphasizing the pathological aspect of the subject's personality and his/her suffering. Conclusion. - Future research should develop adapted and specific diagnosis tools (dimensional and categorical mixed approach), prevention and caring in the elder population. Those studies would be able to determine the link between normal and pathological personality, mortality, depression and dementia. (C) L'Encephale, Paris, 2012.