AT IPA 2016
SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Autism spectrum disorders often are missed in older adults, even though they cause substantial morbidity; identifying these disorders enables clinicians to teach more effective caregiving strategies and adjust medications, which can substantially reduce distress for all concerned, according to Shabbir Amanullah, MD.
About 1% of adults have an autism spectrum disorder (ASD), and so will about 700,000 U.S. seniors by 2030, said Dr. Amanullah, a geriatric psychiatrist at Dalhousie University, Halifax, N.S. Like their younger peers, older patients with ASD show persistent social deficit and rigid thinking, adhere to inflexible routines, and may have perseverative interests. Many also are high-functioning retired professionals with children, belying stereotypes of autism as a severely disabling disorder of childhood, Dr. Amanullah said. These factors can complicate diagnosis of ASD, especially when patients or family members cannot or will not provide a detailed childhood and psychiatric history.
Undetected ASD is especially burdensome in institutional settings, where patients struggle to adjust and “become angry, even violent,” Dr. Amanullah said at the 2016 congress of the International Psychogeriatric Association.
He noted the case of a 72-year-old nursing home resident referred to him for persistently hostile behavior; she “had never really settled in,” slept poorly, and constantly complained about the staff, food, and other residents, whom she “smacked on the bum with her cane.” She also had complained about the facility to local officials, triggering investigations of minor issues. Staff avoided her whenever possible, her children were estranged, and she failed to improve despite therapy with several psychotropic medications.
This is a classic case of autism spectrum disorder, Dr. Amanullah said. The patient acted out most in high-stimulus environments such as the crowded nursing home cafeteria, and interpreted promises to help her “in a minute” literally, becoming enraged when staff arrived 5 minutes later instead. When questioned, she reported having always been “disliked” and without friends. But instead of ruminating over past wrongs as patients with paranoia tend to do, she became uncomfortable and looked down when describing having been bullied as a child.
All these clues had gone unrecognized, according to Dr. Amanullah. “Nobody gave importance to the real reason this patient was complaining. Staff were distracted by the fact that she’d been employed and had children, and did not recognize that someone with ASD can meet this description,” he said.
But staff members often did know children with autism, and so their frustration often turned to compassion after they were educated about her diagnosis and connected it with her behaviors, he said. The patient, for her part, stopped complaining as much about the food after she was allowed to avoid the dining room during busy times and eat in her room if she wished. She also became less recalcitrant after staff began reviewing her schedule with her each morning. If she avoided her most severe behaviors, a staff person also sat with her to keep her company at the end of the day.
Such changes can make a tremendous difference in and outside of institutional settings, but patients with ASD often also need treatment for concurrent Axis I disorders, Dr. Amanullah said. This patient met that description, and Dr. Amanullah increased her antidepressant dose while tapering her off an antipsychotic. He said he often uses 30 mg citalopram once daily “to great effect” – it can trigger sexual disinhibition, but this usually manifests as inappropriate jokes rather than physical behaviors, he said. All this underscores the need for clinicians to “consider the power of bias” in their thinking, he said. “We have to be willing to change the way we see things, and even more importantly, recognize what the problem was to begin with.”
Dr. Amanullah disclosed no funding sources or relevant financial conflicts.
