LETTER TO THE EDITOR
Year : 2021 | Volume
: 8 | Issue : 1 | Page : 54--55
I wish she had dementia: Pandemic, lockdown, elderly with personality traits, and stress on families
Consultant Psychiatrist, Barwon Health, Geelong, Australia
Dr. Srikala Bharath
Consultant Psychiatrist, Barwon Health, Geelong, Australia Former Professor of Psychiatry, NIMHANS, Bengaluru
|How to cite this article:|
Bharath S. I wish she had dementia: Pandemic, lockdown, elderly with personality traits, and stress on families.J Geriatr Ment Health 2021;8:54-55
|How to cite this URL:|
Bharath S. I wish she had dementia: Pandemic, lockdown, elderly with personality traits, and stress on families. J Geriatr Ment Health [serial online] 2021 [cited 2022 Jan 17 ];8:54-55
Available from: https://www.jgmh.org/text.asp?2021/8/1/54/323104
COVID-19 has brought to the forefront many issues which were down in the list of priorities related to the clinical practice of psychiatry pertaining to the elderly.
One of them is the Personality Disorders or Traits in the elderly. Dementia, Depression, and rarely Late Onset Psychosis have been the focus of my old age psychiatry practice over the past 20 years both in an institution and later in private practice.
Literature review indicates the scarcity of clinical research on the various aspects of personality disorders in the elderly.
Work From Home, and the resulting confinement to the same space and time with the elderly, has made the younger generation of care providers, notice and be affected by the “so far known but ignored” maladaptive patterns of coping, behaving, and responding to their elderly parents/relatives.
Let me elaborate with two cases for whom I provided consultation over the net in 2020.
The first consultation was with the adult offsprings and daughter-in-law of Mrs. R who refused to meet me as I was a “mental doctor.” Mrs. R, 68 years widow, lived with son, daughter-in-law, and 2-year-old grandson. Son being a software engineer worked from home since March 2020. Married daughter lived nearby; she too worked from home. Both children were aware of their mother's “difficult nature” even when their father was alive. Dealing with her became more difficult when their father deceased 10 years ago. However, face-to-face interaction with her was less due to everybody's busy work schedules and social life.
According to the offsprings, since their childhood, their mother latched on to people, demanded a lot from them, and when they did not fulfill her expectations, she threw them out like rubbish; bad mouthed them; as a result did not have good relations with her own in laws, in-laws of son and daughter, and daughter in law. Even her sibs avoided her as much as possible. Over their growing years, Mrs. R apparently made unreasonable demands on her children – that they should not interact with their own uncles and aunts whom she did not like; currently wanted her son to choose her over his own family. Over the years, most interactions with Mrs. R ended in her quickly becoming very angry, shouting, crying, hitting herself to the extent of injuring herself, not eating for days, and voicing of wanting to end her life. Son reported that “working from home” had magnified the issues – in that Mrs. R wanted him to talk with her for long periods, listening to her complaints rather than attend “zoom” meetings for work. Son was also upset that Mrs. R was attached to her only grandchild (grandson) in a selfish manner (could not explain it further). He felt that Mrs. R had no concern toward other's feelings and needs. Daughter reported that Mrs. R talked with her about her various complaints relating to various relatives including daughter-in-law and son well into night-time and did not have any consideration for her daughter's sleep or other responsibilities. The son added that he was reacting more and more angry and yelled at his mother, wife, and his infant son. He was scared that he was becoming like his mother. The daughter-in-law said that unable to deal with Mrs. R. She had made the choice of moving to the rooms on the first floor of the house and even cooked there which incensed Mrs. R more. Both children agreed that Mrs. R thought only about herself and never about them or the child. According to them, Mrs. R had no recent cognitive changes, very good at remembering and recalling recent and past events, totally independent in her daily activities including cooking, using the phone and other gadgets at home. In fact, the son exclaimed “Doc, I wish she had dementia; my wife and I would have understood her difficult behavior and would have been compassionate; we could have coped with that better.”
Diagnosis, in this case was probably, Cluster “B” Personality Traits/Borderline Personality Disorder (BPD). Personality Disorders (PDs) were discussed with the offsprings in the absence of Mrs. R Various management options – psychotherapy, medications were discussed. Support and behavioral strategies were discussed and the session ended after 2 hours of consultation.
Mr. B, 60 years married lady whose spouse was working in an administrative position, lived with her son and daughter-in-law who were software analysts. The family was aware of B's nature of always worrying about not having complete bowel evacuation every day and delaying daily activity toward that over any decades. Reportedly, she had always been mistrustful of people including family members; extremely particular about the way things were done around the house; would not allow others to do it. Earlier, husband, son, and daughter-in-law were out of the house for 12 h of the day; hence were not much affected by B's very lopsided schedule and rituals. Working from home, the family was aghast that she had her breakfast at 2 p.m. and dinner at 11 p.m. in the night. She kept her room all the time locked, did not trust the house help who has been with them for a long time. The family tried to work their schedules around her routines but found it very difficult – any discussion of changing/adapting to others brought in resistance and they found that B actually became more rigid and argumentative or teary.
During consultations over the net, B rationalized all her long-term behaviors, gave reasons for her food fads, rigid schedules, keeping her room locked even from the family members, for her not going out or meeting neighbors and family friends. She accepted to have anxiety and agreed for a short trail of Selective Serotonin Reuptake Inhibitors (SSRIs). A probable diagnosis of Anankastic Personality Disorder was made and was started on Tablet Escitalopram 10 mg nocte.
Personality disorders are enduring patterns of inner experience and behavior that deviate markedly from the expectations of the individual's culture, pervasive and inflexible, stable over time, and lead to distress or impairment in relationships, experiences, and daily living. PDs in general have received little attention in research in India including the recent National Mental Health Survey of India. Recent reviews from the West also comment on the relative sparsity of research on PDs in late-life – enduring features into late life, specific assessment, and treatment in the elderly. It also indicates the prevalence rates ranging from 14.5%–10.7%, Obsessive-Compulsive PD being the most common across studies. Others have pointed out that emotional instability, dysfunctional interpersonal relationships, and depression are the lasting characteristics of those with BPD in old age as was evident with Mrs. R.
The two clients described though, very different in their enduring maladaptive responses, behavior, and diagnoses, were comparable in their functional impairment and highly dysfunctional interpersonal relationships that are identified in follow-up studies to be more stable than specific symptoms. Being in closed spaces during the lockdown of the pandemic, interpersonal conflicts escalated in both the clients' families leading to more dysfunctional relationships and help seeking by the carers. Increased prevalence of PDs among nursing home residents indicate that there is an association between proximity in space, more overt strained relationships and recognition of personality issues by the carers.
With the pandemic continuing to be a reality, working from home, being in proximity of the family members including elders will continue in the near future. First contact health workers such as the physicians, geriatricians, and old age psychiatry need to be cognizant of the strain on family dynamics due to PDs in the elderly and provide the family carers support and skills to deal with them effectively. Translational research in this domain may be a long way away, especially in India; however, case histories and clinical audits can provide the impetus toward this.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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