Acta psychiat. scand. (1975) 51, 327-339 Glostrup State Mental Hospital, Department 0 (Head. G.Magnussen, M.D.), Glostrup, Denmark
PREVALENCE O F MENTAL ILLNESS AMONG 70-YEAR-OLDS D O M I C I L E D I N N I N E C O P E N H A G E N SUBURBS The Glostrup Survey
T. RINDERBOLLERUP
The results of a study on the prevalence of mental diseases and abnormalities among a geographically well-defined group of 70year-olds, all living in nine suburbs of Copenhagen, are submitted and discussed. The total psychiatric morbidity was found to be 15.5 %; 6.4 % suffered from psychoses, males preponderating, and 7.4 % were classified as “neuroses personality disorders”, females preponderating. Only 15 % of the psychotic group were institutionalised. Of the entire material, 5 96 were demented, and this included 1.6 % patients who were severely demented. There was a definite preponderance of males. Of the population, 2.6 % were living in their homes with senile or arteriosclerotic dementia. About 1 % of the population were looked after in their homes despite severe dementia of varying geneses. Hidden morbidity, meaning that the proband had neither been institutionalised nor had consulted a doctor for mental illness within the past 5 years, made up 15 % of the psychotic group and 19.2 % of the group “neuroses personality disorders akoholism”. The total hidden morbidity constituted 2.6 % of the population or 16.5 % of the demonstrated psychiatric morbidity. The prevalence findings are on the whole on a level with those reported from other studies, most of which have been concerned with population groups over 65 years of age.
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Key words. Mental disease - prevalence - 70-year-olds - suburban areas - hidden morbidity - comparative studies.
During the period August 1966 to February 1968 the author undertook a socialpsychiatric study of a population comprising 626 persons aged 70, all of whom were domiciled in nine Copenhagen suburbs on census day, May 1, 1967. This formed the basis for a geographically well-defined group of probands, all born
in 1897.
328 The study was one link in a thorough health survey (medical, psychological, psychiatric, social) of these 70-year-olds who were invited to present themselves for examination at the Glostrup County Hospital and Glostrup State Mental Hospital. The object of the social-psychiatric part of the survey was: 1. To determine the prevalence of mental diseases and abnormalities in a
geographically well-defied group of 70-year-olds; 2. To describe the social-familial conditions under which they were living; 3. To demonstrate any statistically significant relationship between the prevalence of mental diseases and that of certain social-familial conditions (among other things, retirement, loss of spouse, lack of ability for employment, increasing loneliness) which might be imagined to contribute to the development of mental disorders in the elderly; 4. To assess the need for care among the population studied; 5. To form a basis for subsequent follow-up studies. The author had personal interviews with 588 probands or 93.9 % of the population. Information about another 31 probands was obtained from their own doctors or from hospital records. Data are totally lacking only in the case of seven probands (1.1 %). The object of the present paper is to submit the result of the analysis on the prevalence of mental diseases and abnormalities in this population. For details of method, diagnostic criteria, and literature the interested reader is referred to Bollerup (1972).
MATERIAL
O n census day the population included a total of 626 persons 70 years of age, 304 males and 322 females. In the whole of Denmark, the number of 69-yearolds at the beginning of 1966 was 16,934 men and 20,654 women, totally 37,588. (In the Statistical Yearbook for 1967 the number of 70-year-olds is not listed separately). This is about 60 times the population of the present study on census day. As the number of 70-year-olds in the entire country is somewhat lower than that of 69-year-olds, it may be considered that the population which was studied made up rather more than 1/60 of all 70-year-old persons living in Denmark on census day. Out of the 625 probands, 588 were interviewed. Of these, 22.1 % (12.0 % of the women and 32.8 % of the men) had employment outside their homes. The question: “Are you, on the whole, satisfied with life at the moment”? was answered as “Yes” by 94.3 %. Only 4.5 % replied “No”,and the remainder replied “don’t know”. Table 1 presents the distribution by sex and civil status. The percentage of single women was about twice that of the single men. Moreover, it is apparent from the table that the material included about three times as many widows as widowers. About one-third were living alone, females preponderating.
329
Men
No.of
Women %
cases
No.of cases
Total
No.of cases
%
%
RESULTS Diagnoses
Table 2 shows the prevalence of mental diseases and abnormalities in the population of 626 70-year-old persons. The prevalence of psychoses, in terms of rate per 1,000, was 63.9; the rate per 1,OOO of neuroses and personality disorders combined was 73.5. If epilepsy and alcholism are included, 'the total prevalence of psychiatric illness amounted to 155.0 per 1,000 population. Neuroses and personality disorders plus alcoholism made up rather more than half the psychiatric morbidity (83.1 per 1,000). There was significant male preponderance in the group of psychoses (P< 0.01) and reversely a significant female preponderance in the group of neuroses 4- personality disorders (P < 0.01). Intelligence defects were not included. They will be described and published by the psychologist (M. Kyng) who tested the probands by WAIS and other tests. It is noteworthy that apart from the three listed cases of manic-depressive psychosis, seven probands three males and four females had previously suffered from manic-depressive psychosis, but were in a neutral phase on census day. If all of these are combined in one group - a total of ten probands or 15.9 per 1,OOO - manic-depressive psychosis along with arteriosclerotic dementia comprises the largest psychotic group.
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Persons refusing to participate. To gain some impression of whether the 28
probands who refused to take part in the study might be presumed to differ essentially from the 588 interviewed probands in respect to psychiatric morbidity, an investigation was made as to whether any of them had previously been admitted to psychiatric departments or hospitals, i. e., before census day. This was looked up in the Cumulative National Psychiatric Register, Institute of Psychiatric Demography, at the State Mental Hospital in Risskov. AU admissions to Glostrup State Mental Hospital and St. Hans Hospital, which is the long-term psychiatric 21 ACTA PSYC 51:s
330
Men
Total psychoses Epilepsy Neuroses Personality disorders Neuroses Personality disorders Alcoholism
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Population
Women
Total
No.of
Rateper 1,000
No. of cases
Rateper
cases
1,000
No.of cases
Rateper 1s o 0 0
30
98.7
10
31.1
40
63.9
3 3
9.9 9.9
2 24
6.2 74.5
5 27
8.0 43.3
19.7
12+(1)
40.4
19
30.4
9
29.5
37
114.9
46
73.5
2+(2)
13.2
2
6.2
6
9.6
5+(1)
304
322
626
hospital for the municipality of Copenhagen, have been recorded by the Institute of Psychiatric Demography since 1959 and 1953 respectively. However, such recording did not apply to the psychiatric departments in the municipality of Copenhagen on census day. This gives rise to a source of error, as some of the probands in Glostrup and adjacent municipalities had previously been domiciled in the municipality of Copenhagen. With this reservation, it was found that none of those who refused to participate had previously been admitted to a psychiatric department or hospital. This does not indicate that the psychiatric morbidity in the group refusing to participate was essentially higher than in the group of 588 probands agreeing to a personal interview. If it were assumed nevertheless, e. g. that the prevalence of mental illness in the group refusing interview was as high as 500 per 1,000, this would mean a total prevalence of mental diseases and abnormalities in the population of 167.7 per 1,000, i. e., no essential change from the above-mentioned result of 155.0 per 1,000.
331
Table 3. Cases of dementia among a geopgraphically defined group of 7O-year-olds, distributed by sex, severity and prevalence rate per 1000
I No.of cases
Population
304
Rate per 1,OOO
Women No. of cases
322
Rate per 1,OOO
I
Total No. of cases
Rate per 1,OOo
626
Dementia. A distinction was made between severe dementia and dd/moderate dementia. Severe dementia was taken to mean that by reason of his dementia the proband was in need of almost constant care and/or supervision. The total prevalence of dementia according to Table 3 is 49.5 stated as rate per 1,000, of which severe dementia constituted 16.0. or one-quarter of the entire psychotic group. The male preponderance is particularly marked within the group of mild/moderate dementia. Out of the group classified under severe dementia (ten probands), only four were institutionalised, whereas the remainder were living at home. (The time of analysis refers to the time of the interview in the case of the interviewed persons and to census day in the case of those not interviewed). In other words, out of the entire population of 626 probands, six or 0.96 % were looked after in their homes despite severe dementia. In a total of 20 probands, a diagnosis of senile or arteriosclerotic dementia was made. On census day, four were institutionalised, which is 6.4 per 1,OOO, and 16 were living at home, or 25.5 per 1,OOO. Psychoses. Among the entire psychotic group including dementia, six were institutionalised, corresponding to 15 % of the psychotic group. Thus, the great majority of the psychotic probands were living at home. Hidden morbidity Within the psychotic group (40 probands), eight probands or 20 % had been in a hospital or nursing home because of their psychosis within the year prior to census day, and 15 probands or 37.5 % had been institutionalised for their psychosis within the last 5 years prior to census day. In both groups, there was a male preponderance corresponding to the sex distribution in the entire psychotic group. As many as 62.5 % of the psychotic 70-year-olds had not been institutionalisedfor their psychosis within the past 5 years. Thirty-one probands out of the psychotic group, or 77.5 %, had consulted 21'
332 general practitioners because of their psychosis within the last year prior to census day, and 33 probands, or 82.5 %, had consulted general practitioners because of their psychosis within the past 5 years. There is a greater male preponderance than that corresponding to the sex ratio within the entire psychotic group, but the numbers involved are small. The hidden morbidity, meaning that the proband had neither been institutionalised nor had consulted a G. P. for psychosis within the past 5 years, comprised six probands or 15 % of the psychotic group (two cases of schizophrenia, two cases of fairly mild senile dementia, one case of paralytic dementia, and one case of postencephalitic dementia). Within the group “neuroses personality disorders alcoholism” (52 probands), only two had been in a hospital or nursing home for mental disease within the last 5 years prior to census day. Thirty-eight probands, or 73.1 % of the group, had consulted G. P.’s because of mental disease within the last year prior to census day. The same applied to the last 5 years prior to census day. There is a greater female preponderance than that corresponding to the sex ratio in the entire group.
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Table 4. Prevalence (%) of dementia among the elderly population according to investigations in six different countries
Senile and arterimclerotic dementia
Other types of dementia
Total
Kay et al., England (n=297) 65 years old
4.6
1.0
5.6
Primrose,Scatland (n =222) 65 years old
3.6
0.9
4.5
Helgason, Iceland (n =2642) 74-76years old
3.6
1.4
5.0
Bentsen, Norway (n=942) 60 years old
5.3
-
5.3
5.0
-
5.0
3.2
1.8
5.0
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&sen-Moller, Sweden (n=443) 60 years old
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Bollerup (present study) Denmark (n=626) 70-year-olds
333
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Hidden morbidity as defined above made up 19.2 % of the group “neuroses personality disorders alcoholism”. The total hidden morbidity (16 probands) constituted 2.6 % of the population or 16.5 % of the psychiatric morbidity demonstrated.
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Comparative studies
Comparisons are made between various studies of the prevalence of mental diseases in an older population in different countries under ‘Discussion’. The prevalence in per cent of senile and arteriosclerotic dementia and other types of dementia in six different countries is shown in Table 4. In Table 5, the distribution of depressed states among the 70-year-olds in the present study by sex and diagnosis is presented. Table 5 . Depressive states among a geographically defined group of 70-year-olds, distributed by sex and diagnosis
I
Men No.of Rateper 1,000 cases
Endogenous depression Psychogenic depression
3 1
Total
4
Population
304
I
No.of
cases
Rateper No. of 1,000 cases
7 322
I
Rate per 1,000
6 3 2
0 1
13.2
Total
Women
21.7
11
17.6
626
DISCUSSION Prevalence of psychiatric illness
In the present study of 70-year-olds c a 2 e d out in Glostrup, certain cases were not included in the prevalence analysis. These were cases of fairly mild, uncharacteristic nervous symptoms or mild, doubtful cases of dementia which did not fulfill all of the diagnostic criteria. From the population survey on the Danish island of SamsB, Juel-Nielsen (1965) has reported that 45 % of the population over 60 years of age could be classified as “presenting a more or less marked psychiatric disorder”. However, only 15 % of the elderly population “really required examination or treatment by a psychiatrist”. This is in good conformity with the prevalence of psychiatric illness of 15.5 % among the 70-yearolds in the present study. Prevalence of psychosis
The prevalence of psychoses of 6.4 % corresponds to what has been reported in the elderly by a number of others: Bremer (1951), 6.7 %; Essen-Moller (1956),
334 6.1 %; the study in Syracuse, New York by Gruenberg (1961a), 6.8 %; Primrose (1962), 5.9 %; Nielsen (1962), 6.8 %; Bentsen (1970), 6.3 %. Kay et al. (1964) found a higher prevalence, 8.0 %; and Sheldon (1948) a lower one, 3.9 %. Helgason (1973) found a higher prevalence of psychosis, 8.7 %, but then his probands were older, 74-76 years of age. The named studies, apart from Helgason’s, comprised not only 70-year-olds, but the population over 65 (in some studies the population over 60). According to Gruenberg (1961b) and Nielsen (1962), the prevalence of psychosis in the elderly population rises appreciably from the age of 65 and upwards. The fact that the 70-year-olds in the present study exhibited largely the same prevalence of psychoses as found in a number of surveys of a population over 65 might indicate that with respect to psychotic prevalence the 70-year-olds reported on here represent a mean of the elderly population. In the Syracuse study, Gruenberg (1961b) found 3.3 % of the population group 65-75 years to be severely mentally disabled, i. e., they showed “manifest evidence or signs of psychosis, judged to be as disabled by their mental disorders as were the persons who actually were in mental hospitals”. And in the case of the 70-year-olds, Gruenberg (1956) found that 3.0 % were psychotic in the sense, “those who were thought to be at the time of interview as disordered as the least disordered persons in the mental hospitals”. In the present study, a similar group may be defined by deducting from the entire psychotic group those with mild-moderate dementia (3.4 %), which leaves a prevalence of more severe psychosis of exactly the same level, namely, 3.0 %. In Nielsen’s study (1962) of the elderly population on the Danish island of Samse, the prevalence is stated for the individual age groups. In the age group 70-74, it was 6.5 % or exactly the same as in the present study. Schizophrenia
In the present study of 70-year-olds, there were two cases of schizophrenia, corresponding to a prevalence of 3.2 per 1,000. This is precisely on a level with Nielsen’s finding on Sam@, 3.1 per 1,000. Stromgren (1938) found a higher prevalence, 5.3 per 1,OOO. Studying the population over 60 years of age in a Norwegian general practice, Bentsen (1970) found a prevalence of schizophrenia of 5.3 per 1,OOO. However, the latter study was a prevalence study over a 3-year period, not a point prevalence study like the present one. Manic-depressive psychosis
That manic-depressive psychosis - when including persons who were syrnptomfree on census day - was the largest group of psychoses besides arteriosclerotic dementia, fits in with Stromgren’s statement (1964) that manic-depressive psychosis is one of the most common types of mental illness in elderly persons. On the Danish island of Bornholm, Stromgren (1938) found a prevalence of manic-depressive psychosis of 16.6 per 1,000 among the population over 65. This comprised persons with present as well as past disease. Defined in the same way, the present
335 study of 70-year-olds showed a prevalence of manic-depressive psychosis of 15.9 per 1,OOO. In the S m s a study, Nielsen included only persons having symptoms and signs of manic-depressive psychosis or undergoing treatment for this condition. He found 12.1 per 1,000 within the age group 70-74 years. With this definition of manic-depressive psychosis, the corresponding prevalence for the 70-year-olds of the present study is 9.6 per 1,OOO. Kay e f al. (1964) found a prevalence of manic-depressive psychosis of 13.6 per 1,OOO of the elderly population.
Psychogenic psychosis Nielsen (1962) reported a prevalence of psychogenic psychoses of 18.4 per 1,000 of the Samsz population over 65, within the 70 to 74-year-old group as many as 28.2 per 1,000, which is far beyond the finding in the present study of 70-yearolds (6.4 per 1,000). On the other hand, Striimgren (1938) found a prevalence of psychogenic psychoses of only 0.2 per 1,OOO of the Bornholm population over 65.
Senile dementia and arteriosclerotic dementia
The epidemiology of senile dementia has been discussed by, among others, Bergman (1969) and Kay (1972). Several authors have analysed the prevalence of senile dementia and arteriosclerotic dementia combined. Kay et al. (1964) found a prevalence of 45.6 per 1,000, i. e., higher than the prevalence in the present study of 70-year-olds examined in Glostrup, 32.0 per 1,000. On the other hand, the prevalence of other types of dementia (including paralytic dementia) was higher among the 70-year-olds in the present study (17.6 per 1,000) than in the English study by Kay et al. (1964), where it was 10.5 per 1,OOO. Thus, the total prevalence of all types of dementia is approximately the same in both studies: 56.1 per 1,000 in the English study and 49.6 per 1,000 in the present study of 70-year-olds. Primrose in Scotland (1962) as well as Helgason in Iceland (1973) found a prevalence of senile -t arteriosclerotic dementia of 3.6 %. This accords with the present study, where it was 3.2 %. Table 4 lists the total prevalence of all types of dementia in the elderly population, determined by studies in six different countries. The results are very similar, about 5 %. The prevalence of senile and arteriosclerotic dementia in an institution was 6.8 per 1,000 of the population over 65 years of age, according to Kay et al. (1964). Similarly, 6.4 per 1,000 of the 70-year-olds in the present study were institutionalised with one of these types of dementia. According to the English study by Kay and colleagues, 38.8 per 1,000 were at home with senile or arteriosclerotic dementia. This exceeds the finding for the 70-year-olds in the present study, among whom the prevalence was only 25.5 per 1,OOO. For the group “all types of dementia” Kay et al. (1964) found that the cases of dementia in institutions occurred among the elderly population at a prevalence
336 of 7.6 per 1,000. Approximately the same applied to the 70-year-olds in the present study, namely, 8.0 per 1,OOO. Among the 70-year-olds from the present study, there was a preponderance of men with arteriosclerotic dementia. This corresponds with the fact that this type of dementia is on the whole more common among males than females (Slater & Roth (1969)). Among the population of Newcastle over 65 years of age, Kay and colleagues also found more males than females with the “arteriosclerotic brain syndrome”, but - in contrast to the present study they found more females than males with the “senile brain syndrome”. In the present study, senile dementia was found in eight men and not in a single woman. This may seem incongruous as the disease senile dementia is more common among women than among men (Slater & Rorh (1969)). The explanation is presumably in part that the age at onset of senile dementia is lower in males than in females, mean 73.4 years in males and 75.3 years in females (Larsson et al. (1963)).
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Epilepsy
An outline of the morbidity of epilepsy is given by Kurtzke (1972). In addition to the five probands with epilepsy as the main diagnosis in Table 2, another two had epilepsy as a subordinate diagnosis. The total prevalence rate per 1,OOO of epilepsy among the 70-year-olds was thus 11.2. This is in fair accordance with the findings of Hauser et al. in their latest Rochester study (unpublished data), i. e., a prevalence per 1,000 of 8.0 for 70-year-olds, and with Juul-Jensen & Ipsen (1975) in the Danish city of Arhus (242,611 inhabitants), where the prevalence of epilepsy per 1,OOO was found to be 9.3 for males and 8.0 for females in the age group 68-72. On the other hand, the finding in the present study is lower than the result of a study in British general practice in which Pond et al. (1960) found a prevalence of epilepsy of 16.8 per 1,000 among the population over 60 years of age. The difference may be due, among other things, to a difference in the definition of epilepsy between the two studies. In the present study, only definite cases of epileptic fits were included, whereas in the British study by Pond and colleagues, an epileptic was defined as follows: “ a patient who had had epileptic fits of any sort at some time during the two years prior to the time of the survey, or who had been on regular anticonvulsants during this period”. A number of other researchers have found a considerably lower prevalence of epilepsy than was found in the present study. In the first Rochester study, Kurland (1959) found a prevalence rate per 1,000 of only 1.0 among 70-yearolds. G u h u n d s s o n (1966) found a prevalence of 2.0 among 70-year-olds in Iceland. In a study in the British town of Carlisle, Brewis et al. (1966) found a prevalence rate per 1,000 of 4.0 among 70-year-olds. In Jerusalem, Leibowitz & Alter (1968) reported a prevalence of 1.3 in the group of 65 to 74-year-olds. However, these studies are not based on the personal examination of each individual person in the population, as is the present study, and this is presumably one of the reasons for the lower prevalence rate found by the other researchers.
337 Neurosis
The prevalence of neuroses in the population of 70-year-olds in the present study was 43.3 per 1,OOO. This fits in well with Nielsen’s result from Samse of 40.3 per 1,000 for the age group 70-74 years and with Bremer’s report of 50.4 per 1,000 for the population over 65 years of age. On the other hand, it is higher than Essen-Moller’s finding of 13.5 per 1,000 for the population over 60 years old. (In return, his investigations revealed a high prevalence of personality disorders). Several authors have found a considerably higher prevalence of neurosis than was found in the present study. For instance, Kay et al. (1964) found 8.9 % for the population over 65 years old, Sheldon (1948) found 9.4 % for the population over 65, Helgason (1973) 9.9 % for the group of 74 to 76-year-olds, Primrose (1962) 10.4 % among the population over 65, and Bentsen (1970) 19.1 % in a long-term period prevalence study of the population over 60. (Bentsen found, however, a strikingly low prevalence of personality disorders, 0.53 %).
Neurosis 4- personality disorder
Also the prevalence of the total group “neuroses 4- personality disorders” varies somewhat: Nielsen (1962) 6.8 %; present study, 7.4 %; Bremer (1951), 17.6 %; and Bentsen (1970), 19.6 %. A number of authors have found a result around 12 %: Essen-Moller (1956), 12.0 %; Kay et al. (1964), 12.5 %; Primrose (1962), 12.6 %; and Sheldon (1948), also 12.6 %. The much greater variation in the prevalence figures for neuroses and personality disorders than in the case of psychoses is presumably due primarily to differences in diagnostic definition. This includes the definition separating the ill group from the healthy group as well as the definition separating the neuroses from the personality disorders. Among the 70-year-olds in the present study, 27 had neuroses. In 17 of the cases, the diagnosis was either anxiety neurosis or depressive neurosis. There was only one case of obsessive-compulsive neurosis and one of hysterical neurosis. Bentsen (1970) as well as McDonald (1973) found the same distribution of the individual types of neuroses among the elderly population: A predominance of depressive neuroses and anxiety neuroses, with a more uncommon occurrence of hysterical and obsessive-compulsive types. The marked female preponderance among the 70-year-olds with neuroses in the present study accords with the findings of a number of other researchers. (Bergmann (1971), Nielsen (1962), Bentsen (1970), Kay et al. (1964)). Depressive states
In the population study on the Danish island of Sam@, SQrensen & Stromgren (1961) found a prevalence of depressive states of 2 % in the population over 70 years of age. The result among the 70-year-olds in the present study (1.76 %) is very similar (Table 5). In both studies, there was a preponderance of women, and the depressive neuroses predominated.
338 Alcoholism
The prevalence of alcoholism among the 70-year-olds in the present study was 9.6 per 1,000. Bentsen (1970) found a somewhat higher prevalence (13.8 per 1,000) among the population over 60, whereas Nielsen (1962) reported a somewhat lower prevalence (5.1 per 1,000) in the population over 65. On the other hand, Bailey et al. (1965) found a considerably higher prevalence of alcoholism in the age group 65-74 years (22 per 1,000) than was found in the present study. The same definition of alcoholism was used in both studies. It is not unlikely that the difference is real, as the American study is from Manhattan, New York City, whereas all the Danish 70-years-olds were living in suburban areas.
REFERENCES Bailey, M. B., P . W . Haberman & H . Alksne (1965): The epidemiology of alcoholism in an urban recidential area. Quart. J. Stud. Alcohol. 26, 1 9 4 9 . Bentsen, B. G . (1970): Illness and general practice. Universitetsforlaget, Oslo. Bergmann, K. (1969): The epidemiology of senile dementia. Brit. J. Hosp. Med. 2, 727-734. Bergrnann, K. (1971): The neuroses of old age. In Kay, D . W. K.,& A . Walk (eds.): Recent developments in psychogeriatrics, pp. 39-50. Headley Brothers Ltd., Ashford, Kent. Bollerup, T . R . (1972): Om den social-psykiatriske del af 70-Brs undersGgelsen i Glostrup. Nord. psykiat. T. 26, 29-47. Bremer, 3. (1951): A social psychiatric investigation of a small community in northern Norway. Acta psychiat. scand., Suppl. 62. Brewis, M., D . C . Poskanzer, C . Rolland & H . Miller (1966): Neurological disease in an English city. Acta neurol. scand., Suppl. 24, 1-89. Essen-Moller, E . (1956): Individual traits and morbidity in a Swedish rural population. Acta psychiat. scand., Suppl. 100. Gruenberg, E. M . (1956): Epidemiology of mental disorders and aging. In Moore, S. E., H . Houston Merritt & R . J . Masselink (eds.): The neurological and psychiatric aspects of the disorders of aging. Williams & Wilkins, Baltimore, pp. 112-128. Gruenberg, E. M . (1961a): A mental health survey of older people. State Hospitals Press, Utica, New York. Gruenberg, E. M . (1961b): A mental health survey of older persons. In Hoch, P . H., & J . Zubin (eds.): Comparative epidemiology of the mental disorders. Grune & Stratton, New York. Gubmundsson, G . (1966): Epilepsy in Iceland. Acta neurol. scand., Suppl. 25, 1-124. Helgason, T . (1973): Epidemiology of mental disorders in Iceland A geriatric follow-up. In de la Fuente, R., & M . Weisman (eds).: Proceedings of the Fifth World Congress of Psychiatry, Mexico, 1971. Excerpta Med.(Amst.) Sect. VZZZB. Juul-Jensen, P., & J . Zpsen (1975): Incidence and prevalence of epilepsy in Greater Arhus. In preparation. Juel-Nielsen. N . (1965): Some results and experiences from recent epidemiological investigations in Denmark. In: Psychiatric disorders in the aged. Report on the Symposium held by the World Psychiatric Ass., Geigy, London, pp. 12-16. Kay, D . W . K., P . Beamish & M . Roth (1964): Old age mental disorders in Newcastle upon Tyne. Brit J. Psychiat. 110, pp. 146-158, 668-682. Kay, D. W . K . (1972): Epidemiological aspects of organic brain diseise in the aged. In Gaitz, Charles M . (4. Aging ): and the brain. Plenum Press, New York, London, pp. 15-27.
339 Kurland, L. T . (1959): The incidence and prevalence of convulsive disorders in a small urban community. Epilepsia 1 , 143-161. Kurtzke, John F. (1972): Mortality and morbidity data on epilepsy. In Alter, M., & W . A . Hauser (ed.): The epidemiology of epilepsy: A workshop. U.S. Department Of Health, Education and Welfare, pp. 21-38. Larsson, T., T . Sjogren & G . Jacobson (1963): Senile dementia. Acta psychiat. scand., Suppl. 167. Leibowitz, U.,& M . Alter (1968): Epilepsy in Jerusalem, Israel. Epilepsia 9, 87-105. McDonald, C. (1973): An age-specific analysis of the neuroses. Brit. J. Psychiat. 122, 477-480.
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Nielsen, J . (1962): Gerontopsychiatric period prevalence investigation in a geographically delimited population. Acta psychiat. scand. 38, 307-330. Pond, D . A., B. H . Bidwefl L L. Stein (1960): A survey of epilepsy in fourteen general practices. Psychiat. Neurol. Neurochir. (Amst.) 63, 217-236. Primrose, E. J . R . (1962): Psychological illness: A community study. Tavistock Publications, London. Sheldon, J . H . (1948): The social medicine of old age, Oxford University Press, London. Slarer, E., & M . Rorh (1969): Clinical psychiatry. Baillihe, London. Statistisk &bog (1967): Danmarks Statist&, Kgbenhavn. Stromgren, E. (1938): Beitrage zur psychiatrischen Erblehre. Acta psychiat. scand., Suppl. 19. Stromgren. E. (1964): Psychiatric deviations in older people. In From Hansen, P . (ed.): Age with a future. Proceedings of the Sixth International Congress of Gerontology. Munksgaard, Copenhagen. S&ensen, A., & E. Stromgren (1961): Frequency of depressive states within geographically delimited population groups. Acta psychiat. scand., Suppl. 162, pp. 62-68.
Received January 30, 1975
T . Rinder Bolierup, M.D., Department R Glostrup State Mental Hospital 2600 Glostrup Denmark
PREVALENCE O F MENTAL ILLNESS AMONG 70-YEAR-OLDS D O M I C I L E D I N N I N E C O P E N H A G E N SUBURBS The Glostrup Survey
T. RINDERBOLLERUP
The results of a study on the prevalence of mental diseases and abnormalities among a geographically well-defined group of 70year-olds, all living in nine suburbs of Copenhagen, are submitted and discussed. The total psychiatric morbidity was found to be 15.5 %; 6.4 % suffered from psychoses, males preponderating, and 7.4 % were classified as “neuroses personality disorders”, females preponderating. Only 15 % of the psychotic group were institutionalised. Of the entire material, 5 96 were demented, and this included 1.6 % patients who were severely demented. There was a definite preponderance of males. Of the population, 2.6 % were living in their homes with senile or arteriosclerotic dementia. About 1 % of the population were looked after in their homes despite severe dementia of varying geneses. Hidden morbidity, meaning that the proband had neither been institutionalised nor had consulted a doctor for mental illness within the past 5 years, made up 15 % of the psychotic group and 19.2 % of the group “neuroses personality disorders akoholism”. The total hidden morbidity constituted 2.6 % of the population or 16.5 % of the demonstrated psychiatric morbidity. The prevalence findings are on the whole on a level with those reported from other studies, most of which have been concerned with population groups over 65 years of age.
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Key words. Mental disease - prevalence - 70-year-olds - suburban areas - hidden morbidity - comparative studies.
During the period August 1966 to February 1968 the author undertook a socialpsychiatric study of a population comprising 626 persons aged 70, all of whom were domiciled in nine Copenhagen suburbs on census day, May 1, 1967. This formed the basis for a geographically well-defined group of probands, all born
in 1897.
328 The study was one link in a thorough health survey (medical, psychological, psychiatric, social) of these 70-year-olds who were invited to present themselves for examination at the Glostrup County Hospital and Glostrup State Mental Hospital. The object of the social-psychiatric part of the survey was: 1. To determine the prevalence of mental diseases and abnormalities in a
geographically well-defied group of 70-year-olds; 2. To describe the social-familial conditions under which they were living; 3. To demonstrate any statistically significant relationship between the prevalence of mental diseases and that of certain social-familial conditions (among other things, retirement, loss of spouse, lack of ability for employment, increasing loneliness) which might be imagined to contribute to the development of mental disorders in the elderly; 4. To assess the need for care among the population studied; 5. To form a basis for subsequent follow-up studies. The author had personal interviews with 588 probands or 93.9 % of the population. Information about another 31 probands was obtained from their own doctors or from hospital records. Data are totally lacking only in the case of seven probands (1.1 %). The object of the present paper is to submit the result of the analysis on the prevalence of mental diseases and abnormalities in this population. For details of method, diagnostic criteria, and literature the interested reader is referred to Bollerup (1972).
MATERIAL
O n census day the population included a total of 626 persons 70 years of age, 304 males and 322 females. In the whole of Denmark, the number of 69-yearolds at the beginning of 1966 was 16,934 men and 20,654 women, totally 37,588. (In the Statistical Yearbook for 1967 the number of 70-year-olds is not listed separately). This is about 60 times the population of the present study on census day. As the number of 70-year-olds in the entire country is somewhat lower than that of 69-year-olds, it may be considered that the population which was studied made up rather more than 1/60 of all 70-year-old persons living in Denmark on census day. Out of the 625 probands, 588 were interviewed. Of these, 22.1 % (12.0 % of the women and 32.8 % of the men) had employment outside their homes. The question: “Are you, on the whole, satisfied with life at the moment”? was answered as “Yes” by 94.3 %. Only 4.5 % replied “No”,and the remainder replied “don’t know”. Table 1 presents the distribution by sex and civil status. The percentage of single women was about twice that of the single men. Moreover, it is apparent from the table that the material included about three times as many widows as widowers. About one-third were living alone, females preponderating.
329
Men
No.of
Women %
cases
No.of cases
Total
No.of cases
%
%
RESULTS Diagnoses
Table 2 shows the prevalence of mental diseases and abnormalities in the population of 626 70-year-old persons. The prevalence of psychoses, in terms of rate per 1,000, was 63.9; the rate per 1,OOO of neuroses and personality disorders combined was 73.5. If epilepsy and alcholism are included, 'the total prevalence of psychiatric illness amounted to 155.0 per 1,000 population. Neuroses and personality disorders plus alcoholism made up rather more than half the psychiatric morbidity (83.1 per 1,000). There was significant male preponderance in the group of psychoses (P< 0.01) and reversely a significant female preponderance in the group of neuroses 4- personality disorders (P < 0.01). Intelligence defects were not included. They will be described and published by the psychologist (M. Kyng) who tested the probands by WAIS and other tests. It is noteworthy that apart from the three listed cases of manic-depressive psychosis, seven probands three males and four females had previously suffered from manic-depressive psychosis, but were in a neutral phase on census day. If all of these are combined in one group - a total of ten probands or 15.9 per 1,OOO - manic-depressive psychosis along with arteriosclerotic dementia comprises the largest psychotic group.
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Persons refusing to participate. To gain some impression of whether the 28
probands who refused to take part in the study might be presumed to differ essentially from the 588 interviewed probands in respect to psychiatric morbidity, an investigation was made as to whether any of them had previously been admitted to psychiatric departments or hospitals, i. e., before census day. This was looked up in the Cumulative National Psychiatric Register, Institute of Psychiatric Demography, at the State Mental Hospital in Risskov. AU admissions to Glostrup State Mental Hospital and St. Hans Hospital, which is the long-term psychiatric 21 ACTA PSYC 51:s
330
Men
Total psychoses Epilepsy Neuroses Personality disorders Neuroses Personality disorders Alcoholism
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Population
Women
Total
No.of
Rateper 1,000
No. of cases
Rateper
cases
1,000
No.of cases
Rateper 1s o 0 0
30
98.7
10
31.1
40
63.9
3 3
9.9 9.9
2 24
6.2 74.5
5 27
8.0 43.3
19.7
12+(1)
40.4
19
30.4
9
29.5
37
114.9
46
73.5
2+(2)
13.2
2
6.2
6
9.6
5+(1)
304
322
626
hospital for the municipality of Copenhagen, have been recorded by the Institute of Psychiatric Demography since 1959 and 1953 respectively. However, such recording did not apply to the psychiatric departments in the municipality of Copenhagen on census day. This gives rise to a source of error, as some of the probands in Glostrup and adjacent municipalities had previously been domiciled in the municipality of Copenhagen. With this reservation, it was found that none of those who refused to participate had previously been admitted to a psychiatric department or hospital. This does not indicate that the psychiatric morbidity in the group refusing to participate was essentially higher than in the group of 588 probands agreeing to a personal interview. If it were assumed nevertheless, e. g. that the prevalence of mental illness in the group refusing interview was as high as 500 per 1,000, this would mean a total prevalence of mental diseases and abnormalities in the population of 167.7 per 1,000, i. e., no essential change from the above-mentioned result of 155.0 per 1,000.
331
Table 3. Cases of dementia among a geopgraphically defined group of 7O-year-olds, distributed by sex, severity and prevalence rate per 1000
I No.of cases
Population
304
Rate per 1,OOO
Women No. of cases
322
Rate per 1,OOO
I
Total No. of cases
Rate per 1,OOo
626
Dementia. A distinction was made between severe dementia and dd/moderate dementia. Severe dementia was taken to mean that by reason of his dementia the proband was in need of almost constant care and/or supervision. The total prevalence of dementia according to Table 3 is 49.5 stated as rate per 1,000, of which severe dementia constituted 16.0. or one-quarter of the entire psychotic group. The male preponderance is particularly marked within the group of mild/moderate dementia. Out of the group classified under severe dementia (ten probands), only four were institutionalised, whereas the remainder were living at home. (The time of analysis refers to the time of the interview in the case of the interviewed persons and to census day in the case of those not interviewed). In other words, out of the entire population of 626 probands, six or 0.96 % were looked after in their homes despite severe dementia. In a total of 20 probands, a diagnosis of senile or arteriosclerotic dementia was made. On census day, four were institutionalised, which is 6.4 per 1,OOO, and 16 were living at home, or 25.5 per 1,OOO. Psychoses. Among the entire psychotic group including dementia, six were institutionalised, corresponding to 15 % of the psychotic group. Thus, the great majority of the psychotic probands were living at home. Hidden morbidity Within the psychotic group (40 probands), eight probands or 20 % had been in a hospital or nursing home because of their psychosis within the year prior to census day, and 15 probands or 37.5 % had been institutionalised for their psychosis within the last 5 years prior to census day. In both groups, there was a male preponderance corresponding to the sex distribution in the entire psychotic group. As many as 62.5 % of the psychotic 70-year-olds had not been institutionalisedfor their psychosis within the past 5 years. Thirty-one probands out of the psychotic group, or 77.5 %, had consulted 21'
332 general practitioners because of their psychosis within the last year prior to census day, and 33 probands, or 82.5 %, had consulted general practitioners because of their psychosis within the past 5 years. There is a greater male preponderance than that corresponding to the sex ratio within the entire psychotic group, but the numbers involved are small. The hidden morbidity, meaning that the proband had neither been institutionalised nor had consulted a G. P. for psychosis within the past 5 years, comprised six probands or 15 % of the psychotic group (two cases of schizophrenia, two cases of fairly mild senile dementia, one case of paralytic dementia, and one case of postencephalitic dementia). Within the group “neuroses personality disorders alcoholism” (52 probands), only two had been in a hospital or nursing home for mental disease within the last 5 years prior to census day. Thirty-eight probands, or 73.1 % of the group, had consulted G. P.’s because of mental disease within the last year prior to census day. The same applied to the last 5 years prior to census day. There is a greater female preponderance than that corresponding to the sex ratio in the entire group.
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Table 4. Prevalence (%) of dementia among the elderly population according to investigations in six different countries
Senile and arterimclerotic dementia
Other types of dementia
Total
Kay et al., England (n=297) 65 years old
4.6
1.0
5.6
Primrose,Scatland (n =222) 65 years old
3.6
0.9
4.5
Helgason, Iceland (n =2642) 74-76years old
3.6
1.4
5.0
Bentsen, Norway (n=942) 60 years old
5.3
-
5.3
5.0
-
5.0
3.2
1.8
5.0
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&sen-Moller, Sweden (n=443) 60 years old
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Bollerup (present study) Denmark (n=626) 70-year-olds
333
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Hidden morbidity as defined above made up 19.2 % of the group “neuroses personality disorders alcoholism”. The total hidden morbidity (16 probands) constituted 2.6 % of the population or 16.5 % of the psychiatric morbidity demonstrated.
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Comparative studies
Comparisons are made between various studies of the prevalence of mental diseases in an older population in different countries under ‘Discussion’. The prevalence in per cent of senile and arteriosclerotic dementia and other types of dementia in six different countries is shown in Table 4. In Table 5, the distribution of depressed states among the 70-year-olds in the present study by sex and diagnosis is presented. Table 5 . Depressive states among a geographically defined group of 70-year-olds, distributed by sex and diagnosis
I
Men No.of Rateper 1,000 cases
Endogenous depression Psychogenic depression
3 1
Total
4
Population
304
I
No.of
cases
Rateper No. of 1,000 cases
7 322
I
Rate per 1,000
6 3 2
0 1
13.2
Total
Women
21.7
11
17.6
626
DISCUSSION Prevalence of psychiatric illness
In the present study of 70-year-olds c a 2 e d out in Glostrup, certain cases were not included in the prevalence analysis. These were cases of fairly mild, uncharacteristic nervous symptoms or mild, doubtful cases of dementia which did not fulfill all of the diagnostic criteria. From the population survey on the Danish island of SamsB, Juel-Nielsen (1965) has reported that 45 % of the population over 60 years of age could be classified as “presenting a more or less marked psychiatric disorder”. However, only 15 % of the elderly population “really required examination or treatment by a psychiatrist”. This is in good conformity with the prevalence of psychiatric illness of 15.5 % among the 70-yearolds in the present study. Prevalence of psychosis
The prevalence of psychoses of 6.4 % corresponds to what has been reported in the elderly by a number of others: Bremer (1951), 6.7 %; Essen-Moller (1956),
334 6.1 %; the study in Syracuse, New York by Gruenberg (1961a), 6.8 %; Primrose (1962), 5.9 %; Nielsen (1962), 6.8 %; Bentsen (1970), 6.3 %. Kay et al. (1964) found a higher prevalence, 8.0 %; and Sheldon (1948) a lower one, 3.9 %. Helgason (1973) found a higher prevalence of psychosis, 8.7 %, but then his probands were older, 74-76 years of age. The named studies, apart from Helgason’s, comprised not only 70-year-olds, but the population over 65 (in some studies the population over 60). According to Gruenberg (1961b) and Nielsen (1962), the prevalence of psychosis in the elderly population rises appreciably from the age of 65 and upwards. The fact that the 70-year-olds in the present study exhibited largely the same prevalence of psychoses as found in a number of surveys of a population over 65 might indicate that with respect to psychotic prevalence the 70-year-olds reported on here represent a mean of the elderly population. In the Syracuse study, Gruenberg (1961b) found 3.3 % of the population group 65-75 years to be severely mentally disabled, i. e., they showed “manifest evidence or signs of psychosis, judged to be as disabled by their mental disorders as were the persons who actually were in mental hospitals”. And in the case of the 70-year-olds, Gruenberg (1956) found that 3.0 % were psychotic in the sense, “those who were thought to be at the time of interview as disordered as the least disordered persons in the mental hospitals”. In the present study, a similar group may be defined by deducting from the entire psychotic group those with mild-moderate dementia (3.4 %), which leaves a prevalence of more severe psychosis of exactly the same level, namely, 3.0 %. In Nielsen’s study (1962) of the elderly population on the Danish island of Samse, the prevalence is stated for the individual age groups. In the age group 70-74, it was 6.5 % or exactly the same as in the present study. Schizophrenia
In the present study of 70-year-olds, there were two cases of schizophrenia, corresponding to a prevalence of 3.2 per 1,000. This is precisely on a level with Nielsen’s finding on Sam@, 3.1 per 1,000. Stromgren (1938) found a higher prevalence, 5.3 per 1,OOO. Studying the population over 60 years of age in a Norwegian general practice, Bentsen (1970) found a prevalence of schizophrenia of 5.3 per 1,OOO. However, the latter study was a prevalence study over a 3-year period, not a point prevalence study like the present one. Manic-depressive psychosis
That manic-depressive psychosis - when including persons who were syrnptomfree on census day - was the largest group of psychoses besides arteriosclerotic dementia, fits in with Stromgren’s statement (1964) that manic-depressive psychosis is one of the most common types of mental illness in elderly persons. On the Danish island of Bornholm, Stromgren (1938) found a prevalence of manic-depressive psychosis of 16.6 per 1,000 among the population over 65. This comprised persons with present as well as past disease. Defined in the same way, the present
335 study of 70-year-olds showed a prevalence of manic-depressive psychosis of 15.9 per 1,OOO. In the S m s a study, Nielsen included only persons having symptoms and signs of manic-depressive psychosis or undergoing treatment for this condition. He found 12.1 per 1,000 within the age group 70-74 years. With this definition of manic-depressive psychosis, the corresponding prevalence for the 70-year-olds of the present study is 9.6 per 1,OOO. Kay e f al. (1964) found a prevalence of manic-depressive psychosis of 13.6 per 1,OOO of the elderly population.
Psychogenic psychosis Nielsen (1962) reported a prevalence of psychogenic psychoses of 18.4 per 1,000 of the Samsz population over 65, within the 70 to 74-year-old group as many as 28.2 per 1,000, which is far beyond the finding in the present study of 70-yearolds (6.4 per 1,000). On the other hand, Striimgren (1938) found a prevalence of psychogenic psychoses of only 0.2 per 1,OOO of the Bornholm population over 65.
Senile dementia and arteriosclerotic dementia
The epidemiology of senile dementia has been discussed by, among others, Bergman (1969) and Kay (1972). Several authors have analysed the prevalence of senile dementia and arteriosclerotic dementia combined. Kay et al. (1964) found a prevalence of 45.6 per 1,000, i. e., higher than the prevalence in the present study of 70-year-olds examined in Glostrup, 32.0 per 1,000. On the other hand, the prevalence of other types of dementia (including paralytic dementia) was higher among the 70-year-olds in the present study (17.6 per 1,000) than in the English study by Kay et al. (1964), where it was 10.5 per 1,OOO. Thus, the total prevalence of all types of dementia is approximately the same in both studies: 56.1 per 1,000 in the English study and 49.6 per 1,000 in the present study of 70-year-olds. Primrose in Scotland (1962) as well as Helgason in Iceland (1973) found a prevalence of senile -t arteriosclerotic dementia of 3.6 %. This accords with the present study, where it was 3.2 %. Table 4 lists the total prevalence of all types of dementia in the elderly population, determined by studies in six different countries. The results are very similar, about 5 %. The prevalence of senile and arteriosclerotic dementia in an institution was 6.8 per 1,000 of the population over 65 years of age, according to Kay et al. (1964). Similarly, 6.4 per 1,000 of the 70-year-olds in the present study were institutionalised with one of these types of dementia. According to the English study by Kay and colleagues, 38.8 per 1,000 were at home with senile or arteriosclerotic dementia. This exceeds the finding for the 70-year-olds in the present study, among whom the prevalence was only 25.5 per 1,OOO. For the group “all types of dementia” Kay et al. (1964) found that the cases of dementia in institutions occurred among the elderly population at a prevalence
336 of 7.6 per 1,000. Approximately the same applied to the 70-year-olds in the present study, namely, 8.0 per 1,OOO. Among the 70-year-olds from the present study, there was a preponderance of men with arteriosclerotic dementia. This corresponds with the fact that this type of dementia is on the whole more common among males than females (Slater & Roth (1969)). Among the population of Newcastle over 65 years of age, Kay and colleagues also found more males than females with the “arteriosclerotic brain syndrome”, but - in contrast to the present study they found more females than males with the “senile brain syndrome”. In the present study, senile dementia was found in eight men and not in a single woman. This may seem incongruous as the disease senile dementia is more common among women than among men (Slater & Rorh (1969)). The explanation is presumably in part that the age at onset of senile dementia is lower in males than in females, mean 73.4 years in males and 75.3 years in females (Larsson et al. (1963)).
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Epilepsy
An outline of the morbidity of epilepsy is given by Kurtzke (1972). In addition to the five probands with epilepsy as the main diagnosis in Table 2, another two had epilepsy as a subordinate diagnosis. The total prevalence rate per 1,OOO of epilepsy among the 70-year-olds was thus 11.2. This is in fair accordance with the findings of Hauser et al. in their latest Rochester study (unpublished data), i. e., a prevalence per 1,000 of 8.0 for 70-year-olds, and with Juul-Jensen & Ipsen (1975) in the Danish city of Arhus (242,611 inhabitants), where the prevalence of epilepsy per 1,OOO was found to be 9.3 for males and 8.0 for females in the age group 68-72. On the other hand, the finding in the present study is lower than the result of a study in British general practice in which Pond et al. (1960) found a prevalence of epilepsy of 16.8 per 1,000 among the population over 60 years of age. The difference may be due, among other things, to a difference in the definition of epilepsy between the two studies. In the present study, only definite cases of epileptic fits were included, whereas in the British study by Pond and colleagues, an epileptic was defined as follows: “ a patient who had had epileptic fits of any sort at some time during the two years prior to the time of the survey, or who had been on regular anticonvulsants during this period”. A number of other researchers have found a considerably lower prevalence of epilepsy than was found in the present study. In the first Rochester study, Kurland (1959) found a prevalence rate per 1,000 of only 1.0 among 70-yearolds. G u h u n d s s o n (1966) found a prevalence of 2.0 among 70-year-olds in Iceland. In a study in the British town of Carlisle, Brewis et al. (1966) found a prevalence rate per 1,000 of 4.0 among 70-year-olds. In Jerusalem, Leibowitz & Alter (1968) reported a prevalence of 1.3 in the group of 65 to 74-year-olds. However, these studies are not based on the personal examination of each individual person in the population, as is the present study, and this is presumably one of the reasons for the lower prevalence rate found by the other researchers.
337 Neurosis
The prevalence of neuroses in the population of 70-year-olds in the present study was 43.3 per 1,OOO. This fits in well with Nielsen’s result from Samse of 40.3 per 1,000 for the age group 70-74 years and with Bremer’s report of 50.4 per 1,000 for the population over 65 years of age. On the other hand, it is higher than Essen-Moller’s finding of 13.5 per 1,000 for the population over 60 years old. (In return, his investigations revealed a high prevalence of personality disorders). Several authors have found a considerably higher prevalence of neurosis than was found in the present study. For instance, Kay et al. (1964) found 8.9 % for the population over 65 years old, Sheldon (1948) found 9.4 % for the population over 65, Helgason (1973) 9.9 % for the group of 74 to 76-year-olds, Primrose (1962) 10.4 % among the population over 65, and Bentsen (1970) 19.1 % in a long-term period prevalence study of the population over 60. (Bentsen found, however, a strikingly low prevalence of personality disorders, 0.53 %).
Neurosis 4- personality disorder
Also the prevalence of the total group “neuroses 4- personality disorders” varies somewhat: Nielsen (1962) 6.8 %; present study, 7.4 %; Bremer (1951), 17.6 %; and Bentsen (1970), 19.6 %. A number of authors have found a result around 12 %: Essen-Moller (1956), 12.0 %; Kay et al. (1964), 12.5 %; Primrose (1962), 12.6 %; and Sheldon (1948), also 12.6 %. The much greater variation in the prevalence figures for neuroses and personality disorders than in the case of psychoses is presumably due primarily to differences in diagnostic definition. This includes the definition separating the ill group from the healthy group as well as the definition separating the neuroses from the personality disorders. Among the 70-year-olds in the present study, 27 had neuroses. In 17 of the cases, the diagnosis was either anxiety neurosis or depressive neurosis. There was only one case of obsessive-compulsive neurosis and one of hysterical neurosis. Bentsen (1970) as well as McDonald (1973) found the same distribution of the individual types of neuroses among the elderly population: A predominance of depressive neuroses and anxiety neuroses, with a more uncommon occurrence of hysterical and obsessive-compulsive types. The marked female preponderance among the 70-year-olds with neuroses in the present study accords with the findings of a number of other researchers. (Bergmann (1971), Nielsen (1962), Bentsen (1970), Kay et al. (1964)). Depressive states
In the population study on the Danish island of Sam@, SQrensen & Stromgren (1961) found a prevalence of depressive states of 2 % in the population over 70 years of age. The result among the 70-year-olds in the present study (1.76 %) is very similar (Table 5). In both studies, there was a preponderance of women, and the depressive neuroses predominated.
338 Alcoholism
The prevalence of alcoholism among the 70-year-olds in the present study was 9.6 per 1,000. Bentsen (1970) found a somewhat higher prevalence (13.8 per 1,000) among the population over 60, whereas Nielsen (1962) reported a somewhat lower prevalence (5.1 per 1,000) in the population over 65. On the other hand, Bailey et al. (1965) found a considerably higher prevalence of alcoholism in the age group 65-74 years (22 per 1,000) than was found in the present study. The same definition of alcoholism was used in both studies. It is not unlikely that the difference is real, as the American study is from Manhattan, New York City, whereas all the Danish 70-years-olds were living in suburban areas.
REFERENCES Bailey, M. B., P . W . Haberman & H . Alksne (1965): The epidemiology of alcoholism in an urban recidential area. Quart. J. Stud. Alcohol. 26, 1 9 4 9 . Bentsen, B. G . (1970): Illness and general practice. Universitetsforlaget, Oslo. Bergmann, K. (1969): The epidemiology of senile dementia. Brit. J. Hosp. Med. 2, 727-734. Bergrnann, K. (1971): The neuroses of old age. In Kay, D . W. K.,& A . Walk (eds.): Recent developments in psychogeriatrics, pp. 39-50. Headley Brothers Ltd., Ashford, Kent. Bollerup, T . R . (1972): Om den social-psykiatriske del af 70-Brs undersGgelsen i Glostrup. Nord. psykiat. T. 26, 29-47. Bremer, 3. (1951): A social psychiatric investigation of a small community in northern Norway. Acta psychiat. scand., Suppl. 62. Brewis, M., D . C . Poskanzer, C . Rolland & H . Miller (1966): Neurological disease in an English city. Acta neurol. scand., Suppl. 24, 1-89. Essen-Moller, E . (1956): Individual traits and morbidity in a Swedish rural population. Acta psychiat. scand., Suppl. 100. Gruenberg, E. M . (1956): Epidemiology of mental disorders and aging. In Moore, S. E., H . Houston Merritt & R . J . Masselink (eds.): The neurological and psychiatric aspects of the disorders of aging. Williams & Wilkins, Baltimore, pp. 112-128. Gruenberg, E. M . (1961a): A mental health survey of older people. State Hospitals Press, Utica, New York. Gruenberg, E. M . (1961b): A mental health survey of older persons. In Hoch, P . H., & J . Zubin (eds.): Comparative epidemiology of the mental disorders. Grune & Stratton, New York. Gubmundsson, G . (1966): Epilepsy in Iceland. Acta neurol. scand., Suppl. 25, 1-124. Helgason, T . (1973): Epidemiology of mental disorders in Iceland A geriatric follow-up. In de la Fuente, R., & M . Weisman (eds).: Proceedings of the Fifth World Congress of Psychiatry, Mexico, 1971. Excerpta Med.(Amst.) Sect. VZZZB. Juul-Jensen, P., & J . Zpsen (1975): Incidence and prevalence of epilepsy in Greater Arhus. In preparation. Juel-Nielsen. N . (1965): Some results and experiences from recent epidemiological investigations in Denmark. In: Psychiatric disorders in the aged. Report on the Symposium held by the World Psychiatric Ass., Geigy, London, pp. 12-16. Kay, D . W . K., P . Beamish & M . Roth (1964): Old age mental disorders in Newcastle upon Tyne. Brit J. Psychiat. 110, pp. 146-158, 668-682. Kay, D. W . K . (1972): Epidemiological aspects of organic brain diseise in the aged. In Gaitz, Charles M . (4. Aging ): and the brain. Plenum Press, New York, London, pp. 15-27.
339 Kurland, L. T . (1959): The incidence and prevalence of convulsive disorders in a small urban community. Epilepsia 1 , 143-161. Kurtzke, John F. (1972): Mortality and morbidity data on epilepsy. In Alter, M., & W . A . Hauser (ed.): The epidemiology of epilepsy: A workshop. U.S. Department Of Health, Education and Welfare, pp. 21-38. Larsson, T., T . Sjogren & G . Jacobson (1963): Senile dementia. Acta psychiat. scand., Suppl. 167. Leibowitz, U.,& M . Alter (1968): Epilepsy in Jerusalem, Israel. Epilepsia 9, 87-105. McDonald, C. (1973): An age-specific analysis of the neuroses. Brit. J. Psychiat. 122, 477-480.
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Nielsen, J . (1962): Gerontopsychiatric period prevalence investigation in a geographically delimited population. Acta psychiat. scand. 38, 307-330. Pond, D . A., B. H . Bidwefl L L. Stein (1960): A survey of epilepsy in fourteen general practices. Psychiat. Neurol. Neurochir. (Amst.) 63, 217-236. Primrose, E. J . R . (1962): Psychological illness: A community study. Tavistock Publications, London. Sheldon, J . H . (1948): The social medicine of old age, Oxford University Press, London. Slarer, E., & M . Rorh (1969): Clinical psychiatry. Baillihe, London. Statistisk &bog (1967): Danmarks Statist&, Kgbenhavn. Stromgren, E. (1938): Beitrage zur psychiatrischen Erblehre. Acta psychiat. scand., Suppl. 19. Stromgren. E. (1964): Psychiatric deviations in older people. In From Hansen, P . (ed.): Age with a future. Proceedings of the Sixth International Congress of Gerontology. Munksgaard, Copenhagen. S&ensen, A., & E. Stromgren (1961): Frequency of depressive states within geographically delimited population groups. Acta psychiat. scand., Suppl. 162, pp. 62-68.
Received January 30, 1975
T . Rinder Bolierup, M.D., Department R Glostrup State Mental Hospital 2600 Glostrup Denmark
