Mental Health and Aging: Chapter 6 Notes PDF

Chapter 6: Mental Health and Aging Copyright © Springer Publishing Company, LLC. All Rights Reserved. Overview  Prevalence of mental health conditions among older adults  Use of mental health services by older adults  Access to mental health care  Diagnosing mental h...

Chapter 6: Mental Health and Aging Copyright © Springer Publishing Company, LLC. All Rights Reserved. Overview  Prevalence of mental health conditions among older adults  Use of mental health services by older adults  Access to mental health care  Diagnosing mental health conditions among older adults  Assessment of mental health conditions among older adults  Empirically supported treatments for older adults Copyright © Springer Publishing Company, LLC. All Rights Reserved. Prevalence  Currently, one in five older adults has a mental health disorder, including dementia. ‒ Number is projected to increase due to the increasing population of older adults in the United States and internationally.  Prevalence of certain mental health conditions declines with age. ‒ Older adults may be more likely to experience “subthreshold” disorders. Symptoms that do not meet criteria for a DSM-5 diagnosis, for various reasons. Copyright © Springer Publishing Company, LLC. All Rights Reserved. Prevalence (cont’d)  Prevalence of mental health conditions among older adults varies by the setting ‒ Major depressive disorder: 14% to 42% among residents of long-term care facilities 5% to 10% among medical outpatients 1% to 5% among community-dwelling ‒ Generally, higher rates of mental health conditions among those in long-term care and those with multiple medical conditions Copyright © Springer Publishing Company, LLC. All Rights Reserved. Use of Mental Health Services  Older adults are unlikely to use psychotherapy when they need it. ‒ Around 70% of older adults with mental health conditions did not use services in the past year. ‒ Use of mental health services is lowest among those with mild mood or anxiety disorders and those of racial-ethnic minority status. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Use of Mental Health Services (cont’d)  Access to mental health care ‒ Why do older adults use fewer mental health services? Researchers suggest that it may be due to beliefs about mental health care, less knowledge about mental health care, and more stigma around obtaining mental health care. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Use of Mental Health Services (cont’d)  Beliefs about mental health care ‒ Older adults may believe that depression is caused by social factors rather than medical factors. Younger adults tend to attribute depression to biological factors. ‒ Older adults more likely to believe that they can handle their problems on their own. ‒ May also have less knowledge about how to recognize the signs of a mental health problem, or when to see a professional. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Use of Mental Health Services (cont’d)  Stigma ‒ Some research suggests that older adults have positive views of mental health care. ‒ However, many report that they would feel embarrassed getting mental health services. ‒ Research on age-related differences in stigma is mixed In some studies, younger adults report more stigma and barriers. In other studies, older adults are more likely to discontinue mental health treatment. African American older adults may endorse more stigma than Caucasian older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Use of Mental Health Services (cont’d)  Stigma (cont’d) ‒ Unclear if low use of mental health services is related to perceived stigma, beliefs about treatment, or lack of access to services. ‒ Low use of mental health services among older adults may be due to cohort effects. Oldest-old adults may have less positive attitudes toward mental health care. This may change as other cohorts enter older adulthood. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults  Mood disorders ‒ Major depressive disorder, dysthymic disorder, bipolar disorder, cyclothymia ‒ Have to distinguish between mood disorders diagnosed when the person was younger versus when the person was an older adult Around 12% of people with mood disorders report that their symptoms appeared after age 60. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Depression ‒ Symptom expression typically differs between younger and older adults. Older adults are more likely to experience anhedonia, less likely to experience sadness. Older adults tend to endorse more somatic symptoms. Cognitive symptoms, psychomotor retardation May make it difficult for health care professionals to sort out depression from other physical conditions Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Anxiety disorders ‒ Among patients older than 60 suffering from a major depressive disorder, nearly 40% also suffer from a comorbid anxiety disorder. ‒ Symptoms of anxiety disorders may decline across the life span and level off after age 80. ‒ Younger and older adults also report different types of worries. Older adults worry more about health and less about work, school, and social issues. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Personality disorders ‒ Tend to be diagnosed at a higher rate among younger than older adults ‒ Most common personality disorders among older adults include: Obsessive-compulsive, schizoid, and avoidant personality disorders Among older adults, personality disorders may be frequently comorbid with anxiety disorders ‒ Certain types of symptoms tend to lessen across the life span Aggressive and impulsive behavior Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Suicidality ‒ Suicide rates generally increase with age. Highest among Caucasian men older than 85 ‒ Depression, family discord, medical illness, poor coping strategies, physical impairments, and higher levels of openness to experience tend to increase the likelihood of suicidal ideation and completed suicide among older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Substance use disorders (SUDs) ‒ Most older adult with SUDs have had substance use problems their whole lives and are now aging. Lack of treatment options for older adults with SUDs ‒ May see an increase in older adults with SUDs due to the aging of the Baby Boomers, who have a more liberal attitude toward drug use. ‒ Most SUD treatment facilities do not have specific programs for older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  SUDs (cont’d) ‒ Commonly misused substances among older adults include alcohol and prescription drugs. ‒ Health care professionals may not ask about substance use among older adults due to implicit assumptions about their use. With prior cohorts (i.e., the silent generation) substance use was uncommon in older adulthood. Current cohorts of older adults may need to be screened for SUDs regularly due to more liberal attitudes toward drug use. Copyright © Springer Publishing Company, LLC. All Rights Reserved. Diagnosing Mental Health Conditions Among Older Adults (cont’d) Figure 6.1 Illicit drug use is increasing among older adults. Source: National Institute on Drug Abuse (2014). Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Sleep ‒ Hard to diagnose sleep problems among older adults because the outcomes of sleep problems (daytime sleepiness, cognitive impairment) overlap with common physical illnesses Cardiovascular problems and so forth ‒ Most common reports of sleep-related issues among older adults involve initiating sleep, maintaining sleep, or awakening during sleep Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Sleep (cont’d) ‒ Sleep problems often related to health Healthy older adults tend to have fewer sleep problems. ‒ Higher mortality associated with short sleep duration (5 hours or less) Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Schizophrenia ‒ Limited research on older adults with schizophrenia. ‒ Older adults with schizophrenia may experience more noticeable declines in mental status and functional ability than younger adults with schizophrenia. ‒ Depression in older adults with schizophrenia has been associated with poor quality of life, smaller social networks, and poor day-to-day functioning. ‒ It can be difficult to decipher whether cognitive impairments are due to schizophrenia or another diagnosis (dementia). Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Diagnosing Mental Health Conditions Among Older Adults (cont’d)  Posttraumatic stress disorder (PTSD) ‒ Distinguish between early- and late-life trauma. ‒ Most of the research focuses on early life trauma (combat experiences, physical/sexual abuse). ‒ Old age alone does not increase the risk of developing PTSD after experiencing trauma. Those with a predisposition to anxiety and depression may be more likely to manifest PTSD symptoms. Copyright © Springer Publishing Company, LLC. All Rights Reserved. Assessment Among Older Adults  Important to determine whether reliability and validity has been established with older adults. ‒ Instruments developed with younger adults may not be psychometrically valid with older adults. ‒ Also, there may not be normative data available for older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Assessment Among Older Adults (cont’d)  Common assessment instruments for older adults for depression: ‒ Center for Epidemiologic Studies Depression Scale (CES-D) for depressive symptoms (short and long versions) ‒ Geriatric Depression Scale (GDS) for depressive symptoms (short and long versions) ‒ Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms (maps onto the DSM-5 criteria) ‒ Cornell Scale for Depression in Dementia (CSDD) Copyright © Springer Publishing Company, LLC. All Rights Reserved. Assessment Among Older Adults (cont’d) Figure 6.2 15-Item Geriatric Depression Scale. Note: Positive responses are in bold. Image obtained from Geriatric Depression Scale (2017). Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Assessment Among Older Adults (cont’d)  Assessment instruments appropriate for older adults are available for several mental health conditions including: ‒ Anxiety disorders/worry ‒ Suicidality ‒ SUDs ‒ Sleep disorders ‒ PTSD Copyright © Springer Publishing Company, LLC. All Rights Reserved. Assessment Among Older Adults (cont’d) Copyright © Springer Publishing Company, LLC. All Rights Reserved. Empirically Supported Treatments Note: Treatments for posttraumatic stress disorder (PTSD) not included in this table because of the limited data for older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Empirically Supported Treatments (cont’d)  Mood disorders and suicidality ‒ Cognitive behavioral therapy (CBT) comparable to pharmacotherapy treatments CBT aims to modify appraisals of situations. ‒ Interpersonal psychotherapy (IPT) addresses the interpersonal relationships of the client Client can focus on grief, role transitions, role disputes, or interpersonal deficits. ‒ Reminiscence therapy Review past events around certain themes Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Empirically Supported Treatments (cont’d)  Anxiety disorders ‒ Pharmacotherapy may have better outcomes than psychotherapy. ‒ In one study, CBT for late-life anxiety had similar effects as active control groups that emphasized validation and supportive listening. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Empirically Supported Treatments (cont’d)  Personality disorders ‒ Dialectical behavior therapy (DBT) Patients taught skills to address mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. ‒ DBT in conjunction with medication was more effective than medication alone for older adults with comorbid depression and personality disorders. Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Empirically Supported Treatments (cont’d)  SUDs ‒ Motivational interviewing is effective with older adults and may improve attendance at therapy and adherence to any medications for substance misuse.  Sleep disorders ‒ Sleep medications may not be beneficial for older adults. ‒ Current recommendation is CBT for insomnia (CBT-I). Utilizes behavioral techniques (sleep hygiene, stimulus control) and cognitive strategies (catastrophizing) Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Empirically Supported Treatments (cont’d)  Schizophrenia ‒ CBT combined with social skills interventions for older adults with schizophrenia May not address other comorbid symptoms, such as depression ‒ Other treatments focus on social skills and independent living Ensure patient’s medical needs are met Copyright © Springer Publishing Company, LLC. All Rights Reserved.  Empirically Supported Treatments (cont’d)  PTSD ‒ Typically treated with exposure, cognitive approaches, and/or narrative/writing approaches Some concern that exposure may be contraindicated for older patients with cardiovascular disease due to the strong physiological reactions that may occur during treatment. ‒ Currently no randomized clinical trials to demonstrate effectiveness with older adults Pilot studies and case studies suggest that exposure is effective with older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved. Conclusions  Older adults use mental health services less frequently than other age groups. ‒ Unclear why and likely is a combination of barriers, beliefs, and stigma.  Mental health problems may present differently among older than younger adults. ‒ Practitioners need to be careful in sorting out physical from mental health problems. Copyright © Springer Publishing Company, LLC. All Rights Reserved. Conclusions (cont’d)  Assessment instruments for older adults need to be selected cautiously to ensure that adequate validity and reliability has been established for this population.  Empirically supported treatments are available that have been studied with older adults. ‒ Can be difficult to find practitioners who are familiar with treatment modifications for older adults. Copyright © Springer Publishing Company, LLC. All Rights Reserved.