1. Introduction
Obsessive-compulsive disorder (OCD) is mostly an early onset and a highly disabling condition, with a lifetime prevalence ranging between 1.5 and 3.5% of the general population and an equal gender distribution [Reference Ruscio, Stein, Chiu and Kessler1].
Prevalence rates seem to decrease with age, ranging between 0 and 0.8% among people aged = 60 years [Reference Bassil, Ghandour and Grossberg2]. Of note, approximately 5% of patients attending specialty OCD clinics are aged 60 or older according to previous and more recent reports [2–Reference Flint4]. OCD seldom begins in late life [Reference Dell’Osso, Benatti, Hollander, Fineberg, Stein and Lochner5], with most patients with geriatric OCD having shown symptoms for decades [Reference Byrne6]. A recent cross-sectional study of the Dutch twin register, including individuals between 15–90 years age range, showed that the age prevalence of OCD and hoarding seem to run a U-shaped curve, with decrease and then increase of OC symptoms after the age of 60, primarily caused by an increase in checking symptoms. It is unclear whether such finding represents a true increase in OC symptom prevalence or may be a compensation mechanism for decrease in cognitive function with age [Reference Cath, Nizar, Boomsma and Mathews7]. Nevertheless, by late life, most individuals with OCD seem to improve, although they may continue to experience clinical or subclinical symptoms [Reference Skoog and Skoog8]. In fact, in case of new-onset OCD after the age of 50 years, in the absence of drug-abuse or other specific medical or psychiatric disorders, neurological diseases should be excluded [Reference Weiss and Jenike9,Reference Slachevsky, Muñoz-Neira, Nuñez-Huasaf, Stern and Blesius10]. For instance, obsessions and compulsions can emerge from a wide range of brain disorders, such as vascular lesions, traumatic brain injuries, central nervous system infections, and neurodegenerative diseases[Reference Wooley, Khan, Murthy, Miller and Rankin11]. Case reports of late-onset OCD have found evidence of cerebral lesions, often in the basal ganglia, which suggest a possible neurodegenerative pathophysiology [Reference Chacko, Corbin and Harper12].
In the attempt to characterize older (age = 60 years) vs younger OCD patients, one of the few reports in the field found that the clinical presentation of the disorder and the severity of symptoms on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) did not substantially differ [Reference Kohn, Westlake, Rasmussen, Marsland and Norman13]. Nonetheless, this study and other reports suggested that geriatric patients with OCD show a later age at onset compared with younger patients and less frequent concerns about symmetry, need to know, and counting rituals, while perseveration about toileting, fear of having sinned and medication schedules were more common [13–Reference Cassidy and Rector16].
With respect to pharmacological treatments, older patients might be particularly sensitive to the anticholinergic, hypotensive, and cardiac effects of tricyclic antidepressants [Reference Cassidy and Rector16]. Selective serotonin reuptake inhibitors (SSRIs), which do not cause these adverse effects, are therefore considered the first-line treatment of OCD in the elderly [Reference NICE17].
In relation to psychotherapy, there has been little evaluation of cognitive-behavioural therapy (CBT) for elderly patients with OCD. Case reports described the use of exposure therapy to successfully treat older people suffering from OCD or phobic avoidance [Reference Flint4]. This intervention, however, was not found to be useful for elderly people with severe physical limitations or moderate to severe intellectual impairment [Reference Calamari, Faber, Hitsman and Poppe18,Reference Leng19].
Given the paucity of available studies in the field of OCD in geriatric patients (G-OCD; age = 65 years) and in order to generate further insight in terms of prevalence, socio-demographic and clinical characterization of the disorder in the elderly, the present multicenter, International study sought to investigate the above-mentioned variables in a large sample of OCD patients, recruited by means of the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) network (www.icocs.org).
2. Methods
The sample included 416 consecutive OCD outpatients of either gender and any age, attending different OCD Clinics worldwide, participating in the ICOCS network. Diagnoses were obtained using the structured clinical interview based on DSM-IV criteria (SCID I and SCID II) [Reference First, Spitzer, Gibbon and Williams20,Reference First, Gibbon, Spitzer, Williams and Benjamin21]. After obtaining patients’ written informed consent and approval from local Ethic Committees/Institutional Review Boards for using patients’ information for research purposes, socio-demographic and clinical variables were collected and included in a common web database. Additional details about the sample assessment have been published elsewhere [Reference Dell’Osso, Benatti, Buoli, Altamura a, Marazziti and Hollander22].
For the purposes of the present study, selected analyzed variables included: age, gender, age of OCD onset, presence of current/past medical illnesses, current pharmacological and psychotherapeutic interventions, lifetime history of suicide attempts and hospitalizations, lifetime presence of comorbid psychiatric disorders and poly-comorbidity (i.e., = 2 comorbid psychiatric conditions), comorbid medical diseases, and OCD severity, measured with the Y-BOCS [Reference Goodman, Price, Rasmussen, Mazure, Fleischmann and Hill23]. The latter was also assessed by means of a qualitative analysis, defining a ‘high severity of illness’ identified by a Y-BOCS score = 24.
The age at onset of OCD was defined as the beginning of individual distress and interference in work, family and social activities associated with obsessions and compulsions.
For the purpose of the study, patients were assessed and first categorized into 2 groups, age < vs = 65 years, and then categorized on the basis of the median age of the whole sample (age < vs = 42 years) in order to further check the results of the first analysis. The threshold of 65 years of age for separating the two groups of patients, though different from the value used in the study by Kohn and coworkers twenty years ago [Reference Kohn, Westlake, Rasmussen, Marsland and Norman13], was selected on the basis of the majority of geriatric medical studies [Reference Nestadt, Bienvenu, Cai, Samuels and Eaton3].
Pearson Chi-squared tests for categorical variables and One-way analysis of variance (ANOVA) for continuous variables were performed to compare the subgroups.
All analyses were two-tailed, used the .05 level of statistical significance and were performed using SPSS 22 for Windows® software.
3. Results
Main socio-demographic and clinical variables of the study sample and related subgroups are reported in Table 1.
Table 1 Main socio-demographic and clinical features of the sample and related subgroups.
* P < .05.
** P < .001.
The whole sample showed a 57.5% female rate, a mean age of 42.9 ± 12.6 years and a mean age at onset of 19.2 ± 9.9 years. Patients with a comorbid psychiatric disorder represented the 23.8% of the whole sample, with Tic Disorder being the most frequent comorbid condition (15.1%) and poly-comorbidity occurring in the 5% of the total sample.
When the total sample was divided in two subgroups, age < vs = 65 years, patients with G-OCD represented a significant minority of the overall sample (n = 24, 6% of the total sample vs age < 65 years: n = 392, 94% of the total sample; P < .001).
Patients with G-OCD showed a significantly later age at onset compared to younger patients (29.4 ± 15.1 vs 18.7 ± 9.2 years; P < .001; Fig. 1). Consistently, in the G-OCD group, adult onset (= 18 years) was found to be significantly more represented (75% vs 41.1%, P < .001). On the other hand, CBT was less frequently utilized in the G-OCD group compared to the younger group (20.8% vs 41.8%, P < .05). Female gender was more represented in the G-OCD group, though not reaching a statistically significant level (75% vs 56.4%, P = .07).
Fig. 1 Differences in age at onset across groups of OCD patients divided on the basis of their current age.
No significant differences in terms of current/past treatment with psychotropic compounds, past suicide attempts, past psychiatric hospitalizations, comorbid psychiatric disorders, psychiatric poly-comorbidity, comorbid medical diseases and severity of illness were found.
Given the limited number of patients in the G-OCD group, to further confirm the results of the first analysis, the whole sample was divided on the basis of the median age of the total sample (age < vs = 42 years, n = 213, 51.2% vs n = 203, 48.8%). The group of OCD patients with age = 42 years showed significantly higher age at onset and rate of adult onset compared to the younger group (respectively 23.01 ± 11.7 years vs 15.7 ± 6.1 years, 75% vs 41.1%; P < .001; Fig. 1). In this analysis, female gender was significantly more represented in the group with age = 42 years (63.1% vs 52.1%, P < .05). No other significant differences were observed.
4. Discussion
To the authors’ knowledge, this is the first multinational study investigating clinical differences between G-OCD vs younger patients suffering from OCD. In this respect, the geographic heterogeneity of the sample should have minimized the risk of possible socio-cultural bias and other confounding factors related to a single catchment area, providing an objective characterization of the phenomenon.
From an epidemiologic point of view, our study showed that G-OCD comprised a small portion of our sample, with only 6% of the patients having an age > 65 years. This prevalence rate seems low when compared to other psychiatric conditions in geriatric patients, such as depression or anxiety disorders (e.g., generalized anxiety disorder), often comorbid, whose prevalence rates are estimated between 1–42% [Reference Djernes24] and 10–20%, respectively [Reference Cassidy and Rector16,Reference Beekman, Bremmer, Deeg, van Balkom, Smit and de Beurs25]. This finding, however, seems to be consistent with one of the few reports available on the topic, comparing clinical features of 32 geriatric vs 601 non-geriatric patients with OCD, revealing a 5.3% elderly prevalence [Reference Kohn, Westlake, Rasmussen, Marsland and Norman13]. In this report, however, authors had used an age threshold of 60 years, different from the present study (65 years), hypothetically indicating an even lower rate in case the same threshold had been used, as done in the present study. In any case, the finding of a low prevalence of G-OCD in our and previous studies, conducted with OCD patients, leaves many open questions, particularly in light of the well-established chronic course of OCD [Reference Visser, Van Oppen, Van Megen, Eikelenboom and Van Balkom26,Reference Rasmussen, Eisen, Davis, Charney, Coyle and Nemeroff27]. On the one hand, in fact, the prevalence finding may simply reflect a cohort effect. However, it may depend on several other factors. For instance, the reported low prevalence of G-OCD in clinical studies might not necessarily reflect a low prevalence of G-OCD in the general population. In clinical studies, in fact, G-OCD patients may be lost to follow-up for different reasons, including a reduced severity of illness with a lower degree of insight and symptoms becoming less egodystonic, the decision to stop treatments due to lack of efficacy, differential mortality and/or predominance of medical comorbidities [Reference Kohn, Westlake, Rasmussen, Marsland and Norman13]. Such hypotheses, however, would imply the presence of different characteristics between G-OCD patients still under follow-up conditions and other subjects suffering from OCD, who never entered or eventually abandoned proper pathways of mental care. Moreover, other authors reported more favorable OCD outcomes with age, showing an improvement in the severity of symptoms after several decades of illness, thus leading to a reduced prevalence of OCD in the elderly [Reference Cath, Nizar, Boomsma and Mathews7,Reference Skoog and Skoog8]. Nonetheless, at the present time, these considerations need further investigation.
In terms of clinical differentiation between G-OCD vs non-geriatric patients, in our sample the former individuals showed a significantly higher age at onset and, consistently, a higher rate of adult onset (as categorical variable) compared with younger patients. Of note, the same results were found when the total sample was divided on the basis of the median age. This result has been already reported in previous investigation [Reference Kohn, Westlake, Rasmussen, Marsland and Norman13] and may suggest that patients with G-OCD exhibit a distinct pattern of illness with later onset and remitting course, significantly different from patients with early onset, more frequent male gender, comorbid Tic Disorder and chronic course [Reference Dell’Osso, Benatti, Hollander and Altamura28].
With respect to late onset in OCD, Eaton et al. [Reference Eaton, Kramer, Anthony, Dryman, Shapiro and Locke29] and, subsequently, Nestadt et al. [Reference Nestadt, Bienvenu, Cai, Samuels and Eaton3] mentioned the possible presence of a bimodal onset in OCD, characterized by a second peak in the elderly. In particular, both peaks (18–29 years and > 65 years) manifested at a higher age in females than in males [Reference Nestadt, Bienvenu, Cai, Samuels and Eaton3]. This finding seems to be replicated in the present study: our sample, in fact, showed a higher female prevalence in the G-OCD subgroup as well as in patients = 42 years. These results are also consistent with the findings of a recent Brazilian study conducted on a large sample of OCD patients, in which authors found that late-onset OCD (= 40 years-old) was more likely to occur in females and that a significant rate of late-onset patients had a history of recent pregnancy [Reference Frydman, do Brasil, Torres, Shavitt, Ferrão and Rosário30]. In addition, a different hormonal role has been hypothesized for distinct subtypes of OCD, even though the precise mechanisms underlying this phenomenon are still unknown [Reference Fontenelle, Mendlowicz, Marques and Versiani31].
With respect to the role of CBT in OCD patients, results from the present study showed a lower rate of treatment with CBT in G-OCD patients, compared to younger patients. It is not surprising that CBT was more used in younger patients, given that this therapeutic approach is considered the first-line treatment in mild to moderate cases of early-onset OCD [Reference NICE17,Reference Geller and March32,Reference Krebs and Heyman33], while medications tend to be reserved to more severe cases and/or to young people who fail to respond to CBT [Reference Watson and Rees34] and, ultimately, to adult patients. Given the cross-sectional nature of this study, older patients may have tried this treatment at their onset without benefits, and did not wish to try it again. In addition, the presence of comorbid medical diseases and cognitive impairment has been reported as responsible for CBT dropouts [Reference Evans35,Reference Albert, Barbaro, Aguglia, Maina and Bogetto36]. Moreover, the availability of CBT might have been increased in recent years and elderly patients might not have had the chance of being treated, or they might not have had the financial resources to afford the treatment [Reference Evans35]. Eventually not all psychiatric services worldwide may have CBT therapists specialized in OCD [Reference Marks, Mataix-Cols, Kenwright, Cameron, Hirsch and Gega37].
In terms of severity of illness, no differences were found across age subgroups, implying that severity of OCD does not seem to change across life, at least in patients under follow-up conditions. Similar results were obtained by Fontenelle et al. [Reference Fontenelle, Mendlowicz, Marques and Versiani31], whose hypothesis was that differences in clinical presentation and in the initial treatment steps of early-onset vs late-onset patients may not result in significant differences in terms of final treatment response in a naturalistic setting.
With respect to psychiatric comorbidity, in our sample, we found no significant association between the presence of comorbidity and age. Interestingly, general psychiatric comorbidity rates appeared to account for approximately one fourth of the total sample, as documented in detail in a previous ICOCS report [Reference Lochner, Fineberg, Zohar, van Ameringen, Juven-Wetzler and Altamura38], this rate being lower compared to other studies [Reference Ruscio, Stein, Chiu and Kessler1] and potentially explaining the lack of significant associations, particularly for Tic Disorder.
The findings reported in the present study should be interpreted in light of some limitations.
The first one is the possible presence of recall bias, since, in most cases, age at onset was retrospectively determined, especially for the oldest patients of the sample. In addition, it needs to be taken into account that centers participating to the ICOCS network have well-established expertise in the field of diagnosis and treatment of OCD and it may be speculated that patients attending such Clinics may have shown higher severity of illness and, therefore, do not necessary reflect the clinical conditions of patients usually observed elsewhere. Furthermore, the severity of illness was measured using the Y-BOCS, with other instruments assessing disability and quality of life (not used in the present study) potentially showing different results across different groups. Finally, reported data may only apply to patients seeking treatment, such population being not necessarily representative of the entire population of OCD patients, particularly in the elderly. Since the multinational nature of the study, specific variables were recorded only in a minority of centers, and some analysis were not performed due to the high percentage of missing data. Further research is, therefore, required to confirm present results and further explore the clinical features of OCD associated with older age, related therapeutic status and overall burden.
Disclosure of interest
E.H. reports grants from Brainsway, grants from Roche, grants from Curemark, grants from Takeda, personal fees from Shire, and personal fees from Sunovion, outside the submitted work. N.F. reports personal fees from Otsuka, personal fees from Lundbeck, nonfinancial support from Janssen, grants and nonfinancial support from the ECNP, personal fees and nonfinancial support from BAP, non-financial support from the World Health Organization, personal fees and nonfinancial support from RANZCP, grants and nonfinancial support from Shire, grants from the National Institute of Health Research, personal fees and nonfinancial support from the College of Mental Health Pharmacists, nonfinancial support from the International Society of Behavioural Addiction, non-financial support from the Royal College of Psychiatrists, nonfinancial support from the International College of Obsessive-Compulsive Spectrum Disorders, nonfinancial support from Novartis, grants and nonfinancial support from Servier, personal fees from Bristol-Myers Squibb, grants from MRC, grants from Wellcome, personal fees from Taylor and Francis, and personal fees from Oxford University Press. D.S. reports personal fees from Lundbeck, personal fees from Novartis, personal fees from the AMBRF, grants from the NRGF, grants from Servier, grants from Biocodex, grants from MRC, personal fees from CIPLA Inc., and personal fees from SUN.
J.G. reports grants from the Trichotillomania Learning Center, grants from the National Institute of Mental Health, grants from the National Center for Responsible Gaming, grants from Brainsway, grants from Forest, grants from Psyadon Pharmaceuticals, and personal fees from Springer Publishing.
B. Dell’Osso, B. Benatti, C.I. Rodriguez, C. Arici, C. Palazzo, A.C. Altamura, H. Nicolini, N. Lanzagorta, D. Marazziti, S. Pallanti, M. Van Ameringen, C. Lochner, O. Karamustafalioglu, L. Hranov, M. Figee, L. Drummond, D. Denys, D. Cath, J.M. Menchon, J. Zohar declare that they have no competing interest.
Acknowledgements
Authors specifically thank the ECNP Obsessive Compulsive and Related Disorders Network (OCRN) for the support.
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