Adjustment Disorders in the Older Adult
Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: email@example.com.
Mrs. D is a 72-year-old widowed woman who was referred for psychiatric evaluation by her primary care physician, Dr. B. Mrs. D is a retired school librarian who worked until three months ago, when her school district had to downsize the library program due to budget problems. She was overwhelmed by the budget cuts and was devastated that the library program that she had worked more than 40 years to create was going to be drastically reduced. Mrs. D was well known to many families and children due to her devotion to the library and the reading programs she had offered for students who needed assistance, which included a program for children with learning disabilities that became a model for other schools.
Following her retirement, Mrs. D started seeing Dr. B frequently with multiple somatic complaints. Dr. B is fond of Mrs. D, as she had helped one of his sons improve his reading skills to above grade level even though his son’s teacher felt that he had a severe reading disorder. Dr. B performed a thorough physical examination and laboratory tests but found no abnormalities. When Dr. B explained to Mrs. D that her health was quite good, she became angry and hostile. She demanded that Dr. B write a letter to the school board in order to reinstate the library program, and he readily agreed. Mrs. D then became even angrier, stating that if people like Dr. B had taken an interest in the community, she would still have a job. Dr. B suggested that she look into volunteer work, given her talents as an educator and her knowledge of libraries and books. She left his office, slamming the door behind her.
Mrs. D returned one week later accompanied by two of her three daughters. They are very concerned about their mother’s anxiety about her future, her fears that she will not have enough money to live on, and her anger. Both daughters are teachers who live nearby and report that Mrs. D is secure financially. Mrs. D has been a widow for the past 10 years and coped well with the loss of her husband. Following his death, she devoted even more time to her job and worked even harder to expand the school library program. Now Mrs. D is spending most of her days writing letters to the school board, teachers, families, and newspapers about the library closings. She often does not leave her house due to episodes of anxiety that occurred when she tried to go out shopping or to a bookstore. She has refused invitations from friends to meet for lunch. Mrs. D admits to Dr. B that she “cannot get the anger out of my head” regarding her forced retirement and feels that the school district just wanted to get rid of her. Dr. B offers her a prescription for an antidepressant medication and suggests that she see a psychiatrist. Mrs. D refuses the medication but agrees to see the psychiatrist.
Aging is associated with multiple stressors, ranging from death of loved ones to coping with chronic medical conditions and loss of roles, including those related to occupations and family life. Older adults frequently must cope with a series of stresses at a time in their lives when uncertainty, life changes, and impairment in physical and mental health status make this task even more challenging.1,2
An adjustment disorder is a psychological or behavioral response to an identifiable stressor that results in significant distress or impairment in social or occupational functioning.3 Associated features of an adjustment disorder may include intrusive thoughts, inability to adapt to change, and avoidance of one’s regular routine. The identifiable stressors4 may be acute (eg, loss of a loved one, retirement, suffering an acute illness such as a hip fracture) or may be chronic (eg, related to ongoing medical conditions such as diabetes and congestive heart failure, moving to an assisted living facility, nursing home placement).
Adjustment disorders are characterized by subtype associated with the predominant symptoms displayed by the patient. There are six subtypes that include both mood and behavioral symptoms1-3 (Table). The symptoms related to the stressor must be present within three months and expected to resolve within three months if the problem is acute in nature. If the stressor is chronic the symptoms may last longer due to the ongoing nature of the stress. The degree of morbidity associated with adjustment disorders is substantial.5 Older adults who suffer from adjustment disorder with depressed mood are more likely to report having poor health status and to be physically dependent in activities of daily living than those who are diagnosed with other mood disorders. Patients who suffer from adjustment disorders have greater anxiety about their health, report significant demoralization, and often display persistent somatization of symptoms despite normal diagnostic results.6
Older adults have a high prevalence of adjustment disorders, ranging from 2% to 8% in community samples.3,4 Among older adults admitted to psychiatric inpatient units, 7% have a diagnosis of adjustment disorder.5 The disorder is equally prevalent in men and women. Mixed emotional features were among the most common subtype in the hospitalized group, and one-third of patients suffered from chronic stressors that resulted in readmission within three years.5,6
Medical inpatients are among those with the greatest prevalence of adjustment disorder. Up to 20% of older adults admitted for acute medical hospitalization suffer from an adjustment disorder, usually with depressed mood.5,6 This is not surprising given the medical stressors that lead to hospitalization. Older adults may also display disturbances of behavior and conduct related to an adjustment disorder. This may lead to refusal of care and rejection of recommended treatment and diagnostic tests. Adjustment disorders are distressing to the patient, time-intensive to the clinician, and costly to the healthcare system.
The differential diagnosis of adjustment disorder must include mood disorders, anxiety disorders, and personality disorders. A thorough evaluation should include attention to any prior psychiatric history and a careful review of acute and chronic stressors. Cognitive testing using a structured instrument such as the Mini-Mental State Examination7 to screen for memory impairment is important in any older adult, particularly one who is dealing with a new or chronic stressor. Patients with a prior psychiatric history are more vulnerable to new stressors, and it is important to consider this in treatment planning. More than 40% of patients who are diagnosed with adjustment disorder have at least one comorbid psychiatric illness.3,4 It is important to screen for patients who are suffering from normal or uncomplicated bereavement, as well as those who suffer from post-traumatic stress disorder. Bereavement is considered when the reaction is part of the normal response to the death of a loved one. Post-traumatic stress disorder and acute stress disorder involve severe or extreme stressors.3 The stressful event or condition that triggers an adjustment disorder may be of any severity.
Treatment of adjustment disorders is largely empirical and based on reduction of the distressing symptoms.7,8 Several types of psychotherapy have been utilized successfully in elderly patients who suffer from depression, anxiety, and bereavement. These may be adapted for the patient with an adjustment disorder. Cognitive behavioral therapy, interpersonal therapy (IPT), problem-solving therapy, and brief goal-directed therapy have been utilized with success.6,8 Engaging the older adult in therapy and establishing a therapeutic alliance are significant factors that are associated with a positive outcome. Involvement of family members and establishing a psychosocial support system are also associated with improvement in symptoms.
The benefit of psychotropic medications for the treatment of adjustment disorders has never been established through controlled trials.3,6 Many clinicians recommend use of antidepressants as adjunctive therapy for chronic and significantly distressing symptoms of anxiety or depression. One interesting study established the benefit of an herbal extract utilized in Europe for the treatment of adjustment disorder with anxious mood.9 Concerns regarding side effects, risks, and benefits of medications should always be discussed with patients prior to the use of psychotropic agents for adjustment disorders, as no drug is FDA-approved for the treatment of this entity.
Outcome of the Case Patient
Mrs. D arrived on time for her appointment with the psychiatrist. She brought a large file containing copies of all of the letters and petitions that she had sent to the school board and local newspapers regarding the library cutbacks. Mrs. D was neatly dressed and groomed. She was well related and very verbal. She expressed to the psychiatrist her feelings of anger, anxiety, and sadness regarding both the loss of her job and the school library reductions. Mrs. D explained that for more than 40 years she had worked hard and felt a strong sense of pride in her accomplishments; she took the loss of her job as a personal failure. She felt ashamed to go out with her friends and have to explain what happened.
Mrs. D had no psychotic symptoms, no suicidal ideation, and her cognition was intact with no signs of cognitive loss. Mrs. D displayed symptoms of anxiety, irritability, and depression that occurred following the stressor of losing her job. She appears to meet the criteria for adjustment disorder with mixed anxiety and depressed mood. Her symptoms were distressing and were interfering with her ability to socialize and leave her home. Mrs. D was suffering from the loss of her role; she was having difficulty with interpersonal relationships, and was unable to transition into other activities that would be of interest to her.
Mrs. D agreed to join a group that utilized an IPT approach to late-life problems. Over an 8-week period she was able to start going out with some of her friends and joined a volunteer tutoring program for children at a local community center. She still spent time circulating petitions and writing letters to try to restore the school library program but was able to balance her time with other activities. At a 6-month follow-up visit, Mrs. D proudly showed the psychiatrist a plaque she received from the school district in honor of her contributions to school literacy.
The author reports no relevant financial relationships.
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