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JOURNAL OF PSYCHIATRIC RESEARCH
CLINICAL PSYCHOLOGY REVIEW
EDITED BY
A.G. AWAD, M.B., Ph.D.
HENRY DUROST, M.D.
H.M. ROSEMARY MEIER, M.B.
ALL OF THE
DEPARTMENT OF PSYCHIATRY
UNIVERSITY OF TORONTO
TORONTO, CANADA
AND
w.o. MCCORMICK, M.B.
DEPARTMENT OF PSYCHIATRY
DALHOUSIE UNIVERSITY
NOVA SCOTIA, CANADA
PERGAMON PRESS
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Copyright © 1987 Pergamon Books, Inc.
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system or transmitted in
any form or by any means: electronic, electrostatic,
magnetic tape, mechanical, photocopying, recording or
otherwise, without permission in writing from the
publishers.
First printing 1987
Library of Congress Cataloging in Publication Data
Disturbed behavior in the elderly.
Bibliography: p.
Includes index.
1. Aged-Mental health services. I. Awad, Awad G.,
1934- . [DNLM: 1. Geriatric Psychiatry-Congresses.
2. Behavior-in old age-Congresses.
WT150 D614 1982-83]
RC451.4.A5D57 1984 362.2Ό880565 84-18016
ISBN 0-08-035131-X
Printed in the United States of America
CONTRIBUTORS
T. Arie, M.D. Professor and Head, Department of Health Care of
the Elderly, Nottingham University, England
A.G. Awad, M.B. Associate Professor, Department of Psychiatry,
University of Toronto; Director, Psychobiological Medicine Unit,
Toronto Western Hospital, Toronto, Canada
B. Lynn Beattie, M.D. Professor and Head, Division of Geriatric
Medicine, University of British Columbia, Vancouver, Canada
Cary Cherniss, Ph.D. Associate Professor, Graduate School of
Applied and Professional Psychology, Rutgers University, New
Brunswick, New Jersey
M.R. Eastwood, M.D. Professor, Departments of Psychiatry and
Preventive Medicine and Biostatistics, University of Toronto; Chief,
Geriatric Psychiatry Service, Clarke Institute of Psychiatry, Toronto,
Canada
Barry J. Gurland, M.D. Professor of Clinical Psychiatry, Director,
Center for Geriatrics and Gerontology, Columbia University, New
York
Lissy F. Jarvik, M.D., PhJD. Professor, Department of Psychiatry
and Biobehavioural Sciences, University of California, Los Angeles;
Chief, Psychogeriatric Laboratory, West Los Angeles Veterans
Administration Medical Center (Brentwood), Los Angeles, California
H.M. Rosemary Meier, M.B. Assistant Professor, Department of
Psychiatry, University of Toronto; Co-ordinator, Geriatric Psychiatry
Service, Toronto Western Hospital, Toronto, Canada
Jim Mintz, Ph.D. Professor, Department of Psychiatry and
Biobehavioral Sciences, University of California, Los Angeles,
California
Duncan Robertson, M.B. Associate Professor and Head, Division of
Geriatric Medicine, University of Saskatchewan, Saskatoon, Canada
Kenneth Shulman, M.D. Assistant Professor and Co-ordinator,
Division of Geriatric Psychiatry, University of Toronto; Chief,
Geriatric Psychiatry Service, Sunnybrook Medical Centre, Toronto,
Canada
Margaret A. Somerville, D.C.L. Associate Professor, Faculties of
Law and Medicine, McGill University, Montreal, Canada
John E. Toner, EdJD. Research Scientist, Center for Geriatrics
and Gerontology, Columbia University, New York, NY; Associate
Psychologist, Harlem Valley Psychiatric Center, Wingdale, New York
D. Wasylenki, M.D. Associate Professor and Director of
Postgraduate Education, Department of Psychiatry, University of
Toronto; Consultant, Community Psychiatry, Clarke Institute of
Psychiatry, Toronto, Canada
David E. Wilder, PhJD. Deputy Director, Center for Geriatrics and
Gerontology, Columbia University, New York, NY
ACKNOWLEDGEMENTS
The Editors acknowledge with very many thanks the skilful
editorial work of Judith Sylph. The extensive process of organizing
the project called upon her many administrative and literary abilities,
and it is thanks to her and her experience that the task was
coordinated with humour and competence.
We acknowledge also with thanks the support and efforts of many
members of staff of the departments concerned, in the planning,
arranging and holding of the conferences. The Ministry of Health and
the University of Toronto are also to be thanked, as they were
involved in several respects, and in particular the Division of
Geriatric Psychiatry and its founding coordinator, Dr. Abraham Miller.
We recognize the contribution to the conferences of Wyeth Ltd.
Canada and Pfizer Continuing Medical Education, and thank the
Royal College of Physicians and Surgeons of Canada for nominating
Professor Arie as the Royal College Lecturer.
INTRODUCTION
The number of publications on age, aging and the aged has
increased rapidly in recent years, just as the number and proportion
of the elderly in the general population has risen, and with it
awareness of the consequences of aging. For the majority of people,
these are personal and social: roles and relationships continue to
develop during yet another stage of life, potentially the most
congenial, with maturity and experience contributing to contentment.
Some of the consequences of aging are, however, adverse. Social
factors, especially reduced finances, may be important, particularly
for women who are widowed. Personal factors such as poor health
may be vital, the more so if mobility or the senses are affected.
Roles within the family are influenced in many ways, notably by the
aging of children: the offspring of the elderly may themselves be
grandparents or have reached retirement. Relationships with friends
can be expected to change, with losses inevitable and a diminishing
circle of friends from earlier stages of life. Where changes in finances,
health and relationships combine, problems arise. These may need
outside help.
There are a number of books available to the many groups which
offer help to the elderly. These are useful to each health discipline
which provides education and training for students and practitioners.
In addition, there is a growing awareness of the team approach,
amplifying the contribution of the various disciplines to assessment
and care. However, fewer books are available on long-term care,
although an increasing proportion of those working with the elderly
are now involved in long-term care, often in ways for which their
basic training did not adequately prepare them.
This book was developed from two conferences which were held
in Toronto, with themes relating to the needs of those giving care as
well as of the elderly themselves. The first conference, 'Disturbed
Behaviour in the Elderly1, was held at Queen Street Mental Health
Centre, was the fourth in a series of annual symposia on topics of
contemporary psychiatric importance, and was organized in
Introduction
conjunction with the Toronto Western Hospital. The second
conference, 'Psychiatry, the Elderly and the Community 1, was
sponsored by the Division of Geriatric Psychiatry of the University of
Toronto, and organized by Whitby Psychiatric Hospital and
Sunnybrook Medical Centre. Both these conferences were innovative,
not only in their focus, but also in the collaboration between
members of staff of provincial government hospitals and teaching
general hospital departments of psychiatry. This growing concern for
the care of the troubled elderly is leading to a specialised interest in
geriatric psychiatry and to the fostering of working alliances among
several disciplines and settings.
The conferences were planned for providers of care for the
elderly, the first more for staff working in institutions and the second
for those active in community programmes. In addition to the
speakers who presented their contributions in person, further
chapters were provided by other specially invited contributors.
During panel discussions at the conferences, it was considered that
certain topics, such as legal aspects of mental health care, and the
'burnout1 of caregivers, had received insufficient attention.
Contributions were invited from specialists in these areas and are
included.
We are grateful to all who have prepared and presented this
array of clinical, theoretical and practical information and
experience, in person and in print, in the midst of lives busy with just
such issues. It is hoped that this book will be useful to those faced
with the complex issues and challenges which present themselves in
the field of geropsychiatry.
CHAPTER 1
A MODEL FOR MULTIDIMENSIONAL EVALUATION OF
DISTURBED BEHAVIOR IN THE ELDERLY
Barry J. Gurland
David E. Wilder
John A. Toner
In common parlance, disturbed behaviour implies that one is
troubled or marked by the symptoms of neurosis or psychosis.* Yet
this definition, which emphasizes subjective and phénoménologie al
features, does not convey the serious impact of the clinical,
administrative and interpersonal problems posed by the patient with
disturbed behaviour. A more appropriate term would be disturbing
behaviour; disquieting to others.
Transactional Model
An essential element in the description of disturbing behaviour is
that it gives rise to complaints by other people. In this sense, the
relevant symptoms are acting-out, anti-social or hard-to-manage
behaviours, which increasingly challenge the capacity of the
community and the long-term care system to deal with the mentally
frail elderly person.
Behaviours which are potentially disturbing are shown in the list
given below. They are organized under captions which give an
indication of the usual reason for their disturbing nature. These
behaviours become particularly disturbing when they are repeated,
prolonged, unpredictable or uncontrollable, or when they are
3
4 Disturbed Behavior
misunderstood and labelled as wilful. They are also disturbing when
they alter the lifestyle, drain the resources or overload the physical
and emotional capacities of those around. The behaviours may be
incompatible with the needs of others for rest and privacy or for
social intercourse.
Potentially Disturbing Behaviours.
Irritating: Noisy, screaming. Perseverating. Stealing.
Pacing, rocking. Nocturnal pottering.
Overactive.
Demanding: Importuning. Reassurance seeking. Unable to
care for self.
Disgusting: Incontinent of urine, feces. Indecent.
Unhygienic. Hoarding.
Puzzling: Hallucinating, deluded. Posturing. Appearing
bizarre.
Depersonalizing: Disoriented. Forgetful. Suspicious, Rejecting.
Unappreciative.
Worrying: Wandering. Non-complying with treatments.
Suicidal. Deteriorating. Refusing to eat.
Frightening: Aggressive. Destructive. Lighting fires.
Carelessness.
Distressing: Suffering. Agitated. Excoriating.
Even where disturbing behaviours are infrequent, they may have
a lasting impact; even one outburst of violence may be enough to
alter permanently the relationship of the patient to others. In a
study by Mesnikoff and Wilder 2, 1900 residents of adult homes
throughout New York State were examined. The sample was not
random but did include a wide variety of types of residence. The
majority of the sample (57%) were 65 years and older. On an 'acting-
out behaviour1 scale only 1 out of 642 elderly subjects was rated as
fpoorf while 95% were rated as good (the remainder were 'fair 1): on
an antisocial behaviour scale, only 3% of the elderly were rated fair
or poor. Corresponding ratings for younger residents were about
twice as high. Nevertheless, administrators of these homes considered
such behaviours to be especially troublesome from their viewpoint.
Those most prone to be disturbed by the patient's behaviour are:
(1) Administrators, staff and residents or attendants in congregate
settings for the elderly, both community-based and institutional. (2)
Direct providers of health or social services in the community. (3)
Housing managers and landlords. (4) Authorities responsible for
