Understanding Personality Disorders in Older Adults

 
Personality disorders in
Older Adults
 
Tier 3
 
What is Personality?
 
The 
word ‘Personality’ refers to the collection of characteristics or
traits that we have developed as we have grown up and which
make each of us an individual. These include the ways that we:
think
feel
behave
 
I
ndividuals with Personality disorders/
complex emotional needs
 
Personality disorder refers to pervasive disturbances within a person’s
personality and behaviour, which can make it difficult for them to live
with 
them
selves and/or other people an
d negatively 
impacts on their
social functioning and relationships.
 
Personality disorders can have a significant impact the ability to
respond to life stresses.
 
People with a personality disorder can feel stigmatised because of
this diagnosis and some prefer the use of the term having complex
emotional needs instead
 
Diagnosis of Personality disorders
 
Diagnosis of personality disorder in older adults is done using the
history
F
rom childhood and early teens it has been difficult to:
make or keep close relationships
get on with people at work
get on with friends and family
keep out of trouble
control their feelings or behaviour
listen to other people
 
 
Recent personality changes
 
Recent personality changes may however not be  due to personality disorder
but rather can be due to:
Medical or organic cause
Cerebrovascular event
Infection – meningitis
Head Trauma
Brain tumour
Dementia
Prescribed Medications
 Steroids
Mental illness
Depression/Mania
Illegal drugs and/ or alcohol
 
Barriers to diagnosis
 
Barriers to diagnosis of a Personality disorder in older adult
Lack of co-informant or co-informant has little knowledge of older
adults’
 early life
Cognitive impairment of patient and/or co-informant
Co-informant’s attitude (e.g. shame, minimisation, embarrassment,
guilt) can affect their account
Severe physical illness in the older 
adult
Reluctance of care team to make the diagnosis
 
 
 
Prevalence of personality disorders (PD)
 
 
Older adults are less likely to attract a diagnosis of
“personality disorder”
​ so exact prevalence is unknown
 
Prevalence could be around  10% of an older community population
 
Overall: Males more than females
 
Most common PD types in old age: Obsessive-compulsive, avoidant
and paranoid.
 
 
 
 
 
Types of Personality disorders
 
Personality disorders tend to fall into three groups, according to their
emotional 'flavour’:
 
Cluster A disorders 
'Odd or Eccentric’ 
(
Paranoid, Schizoid, schizotypal)
- 
seem to remain stable as one gets older although rigid behaviour or
suspicion may increase
 
Cluster B disorders 
'Dramatic, Emotional, or Erratic’ 
(
borderline,
histrionic, narcissistic and antisocial) - 
tend to decrease as one gets
older
 
Cluster C disorders
 'Anxious and Fearful’
 (
Avoidant, Dependent,
Obsessive–compulsive
) - seem to remain stable as one gets older
 
Reasons for presentation
 
Why personality disorders may present in later life
 
They may loose the significant other who has contained or
compensated for the personality disorder in the other person
A move to long term care
Loss of a stabilising situation
Increased use of alcohol and prescription drugs
Retriggering of trauma
Bereavement and losses including loss of jobs/ roles
Difficulty in adapting to ageing
 
Challenges for the older adult
 
Challenges for an older adult with personality disorder
 
Worse physical functioning
Greater use of medication
More unstable/brief relationships
M
ore likely to have other mental health difficulties, like depression
and anxiety
Increased chances of being discharged to a residential placement and
ongoing challenges with forming relationships with carers
Less responsive to treatment 
for
 
any of their 
 
other 
mental illnesses
Older adult with Personality Disorder make up 44% of completed
suicides
 
Challenges for the teams
 
Challenges for the teams caring for an older adult with personality
disorder
Staff receive a lot more calls from this cohort
They may repeatedly ask for prescription medication
They may have frequent attendances to A&E departments
The increased somatization and demands for care from staff/ family
can lead to team frustration and longer admissions
They can lead to splitting among the team members 
(t
his is when
staff begin disagreeing amongst themselves about the best way to
support the person )
 
Core components of support
 
Core components of support for older adults with personality disorders:
 
Establish and understand the importance of the therapeutic relationship
Treat the older 
adults
 comorbidities (e.g. anxiety, depression)
Establish good links with other professionals - 
Have a j
oined up model
between community and inpatient services
Involve significant others where possible
Use supportive cognitive psychotherapy which may help the older 
adult 
to
acknowledge some of these issues and work on them
Training and providing support to carers in helping them understand ways
of managing and offering support
 
 
 
Core components of support
 
Ensure the care team use a systemic approach that fosters
Consistency,
Containment,
Empowerment,
Compassion.
 
References
 
Personality disorders in later life: epidemiology, presentation and management
Ayesha Bangash  BJPsych Advances (2020), vol. 26, 219–220 doi:
10.1192/bja.2020.19
Late-onset personality disorder: a condition still steeped in ignorance   Peter Tyrer
& Robert Howard  BJPsych Advances (2020), vol. 26, 219–220 doi:
10.1192/bja.2020.19
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Personality disorders in older adults can present challenges in social functioning and relationships. Diagnosis involves assessing difficulties in maintaining relationships, controlling behavior, and listening to others. Recent personality changes may not always be due to a personality disorder but could be linked to medical conditions or medication. Barriers to diagnosis include lack of information, cognitive impairment, and reluctance from care teams. The prevalence of personality disorders in older adults is not well-defined but could be around 10% in the community population.


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  1. Personality disorders in Older Adults Tier 3

  2. What is Personality? The word Personality refers to the collection of characteristics or traits that we have developed as we have grown up and which make each of us an individual. These include the ways that we: think feel behave

  3. Individuals with Personality disorders/ complex emotional needs Personality disorder refers to pervasive disturbances within a person s personality and behaviour, which can make it difficult for them to live with themselves and/or other people and negatively impacts on their social functioning and relationships. Personality disorders can have a significant impact the ability to respond to life stresses. People with a personality disorder can feel stigmatised because of this diagnosis and some prefer the use of the term having complex emotional needs instead

  4. Diagnosis of Personality disorders Diagnosis of personality disorder in older adults is done using the history From childhood and early teens it has been difficult to: make or keep close relationships get on with people at work get on with friends and family keep out of trouble control their feelings or behaviour listen to other people

  5. Recent personality changes Recent personality changes may however not be due to personality disorder but rather can be due to: Medical or organic cause Cerebrovascular event Infection meningitis Head Trauma Brain tumour Dementia Prescribed Medications Steroids Mental illness Depression/Mania Illegal drugs and/ or alcohol

  6. Barriers to diagnosis Barriers to diagnosis of a Personality disorder in older adult Lack of co-informant or co-informant has little knowledge of older adults early life Cognitive impairment of patient and/or co-informant Co-informant s attitude (e.g. shame, minimisation, embarrassment, guilt) can affect their account Severe physical illness in the older adult Reluctance of care team to make the diagnosis

  7. Prevalence of personality disorders (PD) Older adults are less likely to attract a diagnosis of personality disorder so exact prevalence is unknown Prevalence could be around 10% of an older community population Overall: Males more than females Most common PD types in old age: Obsessive-compulsive, avoidant and paranoid.

  8. Types of Personality disorders Personality disorders tend to fall into three groups, according to their emotional 'flavour : Cluster A disorders 'Odd or Eccentric (Paranoid, Schizoid, schizotypal) - seem to remain stable as one gets older although rigid behaviour or suspicion may increase Cluster B disorders 'Dramatic, Emotional, or Erratic (borderline, histrionic, narcissistic and antisocial) - tend to decrease as one gets older Cluster C disorders'Anxious and Fearful (Avoidant, Dependent, Obsessive compulsive) - seem to remain stable as one gets older

  9. Reasons for presentation Why personality disorders may present in later life They may loose the significant other who has contained or compensated for the personality disorder in the other person A move to long term care Loss of a stabilising situation Increased use of alcohol and prescription drugs Retriggering of trauma Bereavement and losses including loss of jobs/ roles Difficulty in adapting to ageing

  10. Challenges for the older adult Challenges for an older adult with personality disorder Worse physical functioning Greater use of medication More unstable/brief relationships More likely to have other mental health difficulties, like depression and anxiety Increased chances of being discharged to a residential placement and ongoing challenges with forming relationships with carers Less responsive to treatment for any of their other mental illnesses Older adult with Personality Disorder make up 44% of completed suicides

  11. Challenges for the teams Challenges for the teams caring for an older adult with personality disorder Staff receive a lot more calls from this cohort They may repeatedly ask for prescription medication They may have frequent attendances to A&E departments The increased somatization and demands for care from staff/ family can lead to team frustration and longer admissions They can lead to splitting among the team members (this is when staff begin disagreeing amongst themselves about the best way to support the person )

  12. Core components of support Core components of support for older adults with personality disorders: Establish and understand the importance of the therapeutic relationship Treat the older adults comorbidities (e.g. anxiety, depression) Establish good links with other professionals - Have a joined up model between community and inpatient services Involve significant others where possible Use supportive cognitive psychotherapy which may help the older adult to acknowledge some of these issues and work on them Training and providing support to carers in helping them understand ways of managing and offering support

  13. Core components of support Ensure the care team use a systemic approach that fosters Consistency, Containment, Empowerment, Compassion.

  14. References Personality disorders in later life: epidemiology, presentation and management Ayesha Bangash BJPsych Advances (2020), vol. 26, 219 220 doi: 10.1192/bja.2020.19 Late-onset personality disorder: a condition still steeped in ignorance Peter Tyrer & Robert Howard BJPsych Advances (2020), vol. 26, 219 220 doi: 10.1192/bja.2020.19

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