Personality disorder in elderly

1. Personality disorders in
Older Adults
Tier 2

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. 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.

5. 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

6. 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

7. 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

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

9. Challenges for the teams
Challenges for the teams caring for an older person with personality
disorder
• Staff receive a lot more calls from this cohort
• They may repeatedly ask for prescription medication
• They may have frequent attendance at A&E
• 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 )

10. 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 person’s 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 person
to acknowledge some of these issues and work on them

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

12. 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