Chapter 11

Chapter 11: Mental Health Issues and Treatment
- Some older adults have coped with a mental health issues their whole lives which others
are having new experiences brought on by bereavement or physical illness
- Canadian community health survey found that the most reported need was counselling
and it was also the most unmet need
- Although rates of dementia are higher among older adults they also have lower rates of
anxiety, mood disorders and substance abuse disorders
- Psychological disorders reflect developmental process that continue throughout life
o Sometimes whether or not psychological symptoms start to show later in life
depends on the balance of risk and protective factors as they evolved earlier in life
- Sometimes the difference between normal and abnormal is the degree
Psychological Disorders in Adulthood
- Criteria used to judge behaviour as abnormal include:
o Feeling personal or subjective distress
o Being impaired in everyday life
o Putting the self or others at risk of harm
o Engaging in behaviour that is socially or culturally unacceptable
- Psychological disorders include the range of behaviours and experiences that fall outside
of social norms, create adaptation difficulty for the individual on a daily basis, and put
the individual or others at risk of harm
- People considered to be hoarders might be considered to have a psychological disorder
because they are engaging in behaviour out the accepted norm and putting themselves
and others at risk of harm
- Specific behaviours that meet conditions of abnormality are given diagnosis based the
criteria of the DSM
o Major reference for mental health professionals
- IDC is the international statistical classification of diseases and related health problems
o Used in some parts of the word to diagnose health problems and psychological
o The clinician must decide if a patient meets the minimum number of specific
criteria required for the diagnosis to be applied
o The clinician also rates the severity of the diagnosis in the individual
o Rating that also indicates how much stress the individual is experiencing and the
level of functioning they are demonstrating
o These criteria have a fairly high degree of severity and persistence of symptoms
over a longer period of time – usually 2 weeks
o Applying the diagnostic criteria to older adults has specific challenges
 Many older adults will become widowed
 Major depressive disorder vs bereavement
 Older adults have more chronic illnesses and is it often difficult to
differentiate between symptoms related to chronic illness and those related
to mental health problems
 Many of the symptoms of depression are also symptoms of chronic
o Fatigue, loss of appetite, sleep deprivation
 One of the major criteria for depressive disorder is loss of interest or
pleasure in daily activities
 Older adults who can’t do the things they use to because of chronic
illness or limitations of where they are living would meet that
o DSM diagnostic criteria may not always fit the experiences of older adults and
when used need to be sensitive to the unique challenges older adults face
Selected diagnoses in the DSM as observed in older adults
o Depressive disorder: prolonged sad mood
 Ex, major depressive disorder, persistent depressive disorder
 Important considerations for OA: depression may appear as cognitive
impairment or physical symptoms
o Anxiety disorder: intense anxiety, worry or apprehension
 Ex, generalized anxiety disorder, panic disorder, specific phobia, social
anxiety disorders, agoraphobia
 Important considerations for OA: symptoms of anxiety disorders may
present or coexist with medical symptoms
o Schizophrenia spectrum and other psychotic disorders: psychotic symptoms such
as distortion of reality and serious impairment in thinking, behaviour, affect and
 Ex, schizophrenia, schizoaffective disorder, catatonia disorder, delusional
disorder, brief psychotic disorder, schizotypal personality disorder
 Important considerations for OA: the likelihood of complete remission is
20-25%, the lifetime risk of suicide among people with schizophrenia is
much higher than the general population
o Neurocognitive disorders: significant loss of cognitive functioning as a result of
neurological dysfunction or medical illness
 Ex, delirium, major or mild neurocognitive disorder
 Important considerations for OA: delirium may be misdiagnosed as
o Substance-related and addictive disorders: use of, intoxication by, or withdrawal
from psychoactive substances
 Ex, alcohol use disorder, sedative hypnotic or anxiolytic related disorders
 Important consideration for OA: older adults are more at risk than is often
Older adults with mental health problems is a very diverse group
o Some have had life-long struggles and other have their first episode late in life
and some are inbetween
o Older adults with chronic mental illness can present very differently than those
with late onset disorder
o Coping with lifelong mental illness bring a unique set of challenges:
 Loss of social support from family and friends
 Loss of income due to inability to maintain employment or chronic
 Lifetime exposure to stigma
 Negative effects of early psychotropic drugs used to treat
 Even institutionalizations in mental hospitals
- Important distinction between exhibiting all criteria for diagnosis and experiencing some
of the symptoms of the disorder
o Especially true with older adults who might not meet all criteria of diagnosis but
may exhibit some symptoms
Major Depressive Disorder:
- Individuals who experience prolonged and extreme sadness may be diagnosed with a
form of depressive disorder if symptoms are severe enough and last long enough
- Major depressive disorder
o Major symptom is an extremely sad mood that lasts most of the time for a period
of at least 2 weeks and is not typical for the individual’s behaviour or usual mood
o Individual may also experience other symptoms
 Appetite or sleep disturbances, feelings of guilt, difficulties concentrating,
low sense of self worth
- Women are at higher risk than men for being diagnosed with depressive disorder
- Adults 60 and over are at a lower risk of being diagnosed than those 59 and younger
- Women more likely to experience the diagnosable condition the depressive symptoms are
higher in men 60-80
o Rates of the symptoms level off here between sexes
- Traditionally recognized psychological symptoms of depression are less likely to be
acknowledged by older adults
o Older adults are more likely to seek medical attention for physical symptoms
- Health care professional are not well trained in recognizing symptoms of depression in
older adults
o Also has to do with older adults not reporting their symptoms to allow for
- Providers are not attuned to the psychological disorders in their older clients
- Also less time is spent with older adults during health care visit then younger patients
- Health care plans provide little reimbursement for mental health services
o Long wait times in public clinics, expensive private clinics
- Many mental health problems among the elderly could be prevented with early diagnosis
and appropriate treatment
- Mental health system places more importance on treatment than prevention and health
- Attitudes towards depression among health professionals could be problematic
o Some assume that depression and its symptoms are a natural part of aging and pay
less attention to them
o Some health care workers want to avoid stigmatizing older adults so won’t
diagnose them
o May also be misdiagnosis because symptoms of mood disorders occur in
conjunction with medical conditions and health care workers ignore mental health
and think it is physical thing
- Trying to determine the cause of an older adults depression needs to include looking for
possible contributing psychosocial factors
o Functional limitations
o Inability to provide basic self-care
o Pain
- Changes in cognition and personality especially among oldest old are risk factors
- Institutionalizations is another risk factor for depression
o Stressful life events like bereavement, loneliness and others are risk factors as
 Middle and older adults this is need
- Inability to employ successful coping strategies to deal with life stressors can increase the
risk of developing depression
o Study found those with ineffective coping methods like avoidance were more
likely to develop symptoms of depression than those who attempted to handle
stressors through direct problem solving mechanisms
- Medical disorders also present significant risk for depression
o Arthritis related activity limitations
o Hip fracture
o Stroke
o Diabetes
o Hypertension
o Metabolic syndrome
- Potentially overlooked risk factor is lack of vitamin D
o Also a risk factor for cognitive impairment
- Older adults become more likely to suffer further impairments in physical and cognitive
functioning when their psychological symptoms are untreated
- Depressive symptoms predict mortality in older adults
o Through immune system possibly
- Depression may activate cytokines and eventually increase the risk of CVD, diabetes,
osteoporosis, arthritis, frailty and functional declines
- Major depressive and chronic depressive disorder can increase risk of developing a
neurocognitive disorder
- Not a diagnosis in the DSM
- Is it related to psychological disorders that are in the DSM
- Some form of mental illness is the most important risk factor for suicide
o Can also occur as a result of a combinations of risk factors
 Martial breakdown, financial hardship, major loss, deteriorating physical
health, lack of social support
- Risk factors:
o Depression and other psychological disorders
o Substance abuse disorder or combination of substance abuse with another disorder
o Prior suicide attempt
o Family history of psychological disorder or substance abuse
o Family violence, sexual abuse, physical abuse
o Firearms in the home
o Incarceration
o Exposure to suicidal behaviours of others
 Many people have these risk and are not suicidal
Men are 3 times more likely to commit suicide than females
Married people less likely than single, divorced or widowed people
Those 40-59 are at the highest risk
Men 85+ found to have highest mortality rated due to suicide
Several risk factors among older adults
o Psychiatric illness particularly depression
o Physical illness and limitations in functioning
o Chronic pain
o Deficits in cognitive functioning
o Social isolation and stressful life events
- Suicide can be understood as a biopsychosocial phenomenon
o Biological factors- illness and functional losses
o Psychological factors- cognitive changes and depression
o Social factors- stress and isolation
- Key identifier of older adults at risk are those with a history or self-harm
- Older adults contemplating suicide may show no signs of depression
- Subclinical symptoms showed by suicidal older adults include hostility, sleep
disturbances, anxiety and depression
- Rational suicide:
o A sane and well throughout decision by an individual who is mentally competent
and who is capable of reasoning and choosing the best alternative among those
o Individual facing life limiting and painful illness may choose suicide is best
 They do not have the typical suicidal representation but are at significant
- Almost half of all suicide victims saw their health care professional in the past month
o Need to be more sensitive to symptoms and have multidisciplinary approach
Bipolar Disorder:
- Diagnosed in people who have experienced one or more manic episode in which they feel
elated, grandiose, expansive and highly energetic
- They may or may not have experienced period of significant depression along with being
- Most cases of diagnosed bipolar disorder are in people under 25
- Researchers know less about bipolar disorder in OA then they do major depressive
- Rates are lower in older adults than younger people
- Neurological contributions in older adults related to higher risk of cerebrovascular
disease and white matter hyper intensities
- Bipolar disorder exacts a high psychosocial cost on those who have experienced its
o Older adults with a life time of rapid cycling feel their goals couldn’t be met as
well or were derailed completely
- People can however live symptom free with proper treatment
Anxiety Disorder:
- Main characteristic is anxiety
o A sense of dread about what may happen in the future
- Having unpleasant feelings associated with anxiety people with anxiety disorders go to
great lengths to avoid anxiety provoking situations
o May have difficulty performing in their jobs, enjoying leisure activities and
engaging in social activities with friends and family
- Most high prevalence out of all disorders other than substance abuse
- Anxiety peaks at age 30-44 and sharp drop in those 60 and older
o Older adult’s least likely
- Older women 5x higher risk than older men of being diagnosed with anxiety disorders
- Lower rates among OA could reflect their resilience or because health workers not well
trained at recognizing anxiety in older adults
- May present or coexist with medical symptoms
- Generalized anxiety disorder is when the individual experiences an overall sense of
uneasiness and concern without a specific focus
o Very prone to worrying over minor things
o Symptoms
 General restlessness, trouble concentrating, irritability, difficulty sleeping
o Medical patients have higher risk of GAD
Trauma and Stress Related Disorders:
- Exposure to trauma like earthquake, fire, physical assault or war can lead people to
experience symptoms that may last for a prolonged period of time
- Symptoms
o Intrusion of distressing reminders of the event
o Dissociative symptoms
 Feeling numb or detached from others
 Avoidance of situations that may be reminders of the event
 Hyper arousal
 Sleep disturbances and irritability
- Symptoms for up to a month usual acute stress disorder
- Symptoms for longer than a month is post-traumatic stress disorder
- Severe health problems such as heart disease can increase a persons’ risk of developing
PTSD after combat
- Late onset stress symptomatology (LOSS)
o Aging veterans who were exposed to combat early in life and symptoms don’t
start until later
 Could start to emerge as a function of stressful events associated with
 Bereavement or increased health problems
o Similar symptoms to PTSD just start later in life
Schizophrenia and Psychotic Disorders:
- Disorder in which the person experiences distorted perception of reality and impairment
in thinking, behaviour, affect, and motivation
- Don’t experience all symptoms continuously but to be diagnosed they must have played a
significant role in the past month
- Symptoms include
o Delusion (false beliefs)
Hallucinations (false perceptions)
Disorganized and incoherent speech
Abnormal motor behaviour
Negative symptoms of apathy
 Lack of emotional expression and withdrawal
- While the symptoms are active it is hard for the person to hold a job or relationship or
take care of themselves
- DSM says the symptoms must of lasted for 6 months or more and the person cannot have
another diagnosis that would possibly explain the symptoms
- Higher rates for adults 35-44 and lower for those under 65
- Decrease in prevalence at older ages is due to the fact that a lot of people with diagnosis
don’t live until old age
- People with schizophrenia have higher rates of CVD and metabolic disorders
- They also experience feelings of isolation and an identity of being different
- Older adults with schizophrenia have higher suicide rates
- Older adults who have suffered from schizophrenia for many years develop a wide range
of coping skills that are helpful
- Course and outcome of schizophrenia are poorer than other psychological disorders
- Some people can show full recovery sometimes
- Late onset schizophrenia
o Form of the disorder thought to originate in people after the age of 45
o Condition is now thought to be something else not schizophrenia
o Risk factors include sensory deficits, comorbid dementia, delirium, social
isolation and substance abuse
o Some other psychotic disorder
Substance Related Disorders:
- Most often alcohol abuse or dependence
- The majority of adults with these disorders are teens to those in their 20s
- Percentage of older adults is on the rise now with the aging of the baby boomer
- Older adults are more vulnerable to the effects of alcohol because they metabolize it more
o It can exacerbate already existing health problems and can potentially interact
with the medications that older adults take
- Sometimes hard to detect alcohol dependency in OA because they are isolated and don’t
leave their homes
- Some OA may attribute falls, ill-health, or poor self-care to aging rather than alcohol
- People who abuse alcohol tend to not live past 60s or 70s
o By the time they reach 70 are either dead or have become abstinent
- Some people start drinking later in life in response to health problems or psychosocial
- Alcohol use is common in the settings older people live- nursing home, retirement
- People with a history or problem drinking and those retired involuntarily are at great risk
of abusing alcohol after retiring
Risk of alcohol abuse among older adult’s ranges from cirrhosis (liver), heightened rate
of injury and hip fractures, car accidents
o Increased risk of diabetes, high blood pressure, congestive heart failure,
osteoporosis, mood disorders
- Even without change in drinking patterns older people may experience difficulties
associated with physiological changes in the kidneys that effect tolerance
- Long term there can be changes to frontal lobe and cerebellum that speed up the effects
of natural aging on cognitive and motor functioning
- Severe cases dementia may develop leading to permanent memory loss and death
- The misuse of medications is an issue for older adults
o They are often taking more than one
o Highest rates of sedative and tranquilizer use
o Most of them do not take their medications properly
- Many older adults enjoy gambling as a social activity
o Rates of gambling problems are though to the same for older adults as for any
other age group maybe even lower
Treatment Issues in Mental Health Care
- Training models have been developed in the emerging field of professional
o Application of gerontology to the psychological treatment of older adults
- Pikes Peak Model of Geropsychology
o Set of competencies that professional geropsychologists are expected to have
when working with older adults
- Because of the aging population and the speculation that the baby boomer generation will
be more likely to seek help from mental health professional the need it growing
- Clinicians who work with adult populations recognize the need to differentiate the
approaches they use with each age group
- Guidelines from the geropsychology
o Attitudes: be aware of the attitudes and beliefs about aging
o General knowledge: gain expertise in aging
o Clinical issues: understand psychopathology in older adults
o Assessment: learn to use and interpret appropriate tools
o Service provision: know about efficacy of interventions
o Education: gain continuing education in geropsychology
- Need to take into account the possible effects of chronic disorders and normal age related
changes in physical, cognitive, and social functioning
- Psychological assessment is a procedure in which a clinician provides a formal evaluation
of an individual’s cognitive, personality, and psychological functioning
o Use it provide a diagnosis or to determine an OA level of competence
- Tailor each assessment to the physical and cognitive needs of the individual
o Take into account physical limitations due to arthritis or that the OA may need
more breaks
o Need to limit distractions around the OA
- Clinical interview
o Face to face questions administered with the client
Mental status examination
o Assesses the clients current state of mind
 Qualities of appearance, attitudes, behaviour, mood, speech thought
processes, content of thought, perception insight
- Orientations reflects whether the person knows where they are, what time it is, and who
they are
- Mini mental state examination used to detect dementia
o Not used too much because can’t say type of neuropsychological disorder
- Key area in differential diagnosis is to distinguish between dementia and other
psychological disorders mainly depression
o Depression can cause pseudo dementia and lead to an OA being misdiagnosed
with dementia
o Patterns of symptoms differ
 Depression the symptoms of dysphoria are more sever and the individual
is more likely to exaggerate their level of memory loss
 Dementia the individual is more likely to be over confident in their
cognitive abilities
o People with depression may show wide variations in performance tests and those
with dementia are more likely to show a progressive decline in ability
o Timing of symptoms
 Older adults with depression experience cognitive symptoms prior to
depressive symptoms
 If cognitive symptoms persist after the depression is treated is more likely
to be dementia
- In addition to psychological assessments important evaluate the ability to perform ADLs
and instrumental ADLs
- Best mental health treatment follows a biopsychosocial model
o Take into account complex interactions between the client’s physical symptoms,
health, cognitive abilities, emotional strengths, personality, sense of identity and
social support network
- Older adults benefit from integrated model of care
o Bring together nurses, physical therapy, occupational therapy, clinical
psychology, social medicine
o Older adults more likely to seek help from their general doctor than a mental
health professional
o Also there is a need to avoid dangerous interactions among medications
- Most clinicians operate from medical model
o Treat psychological disorders primarily with medications
 OA these medications may interact with the other ones they are taking for
their chronic illness- integrated model is needed
- SSRI for depression and anxiety are often prescribed
- Beta blockers also used for anxiety but OA with CVD can’t use these
- OA less likely to benefit from
o Perceived need and attitudes toward mental health treatment and therapist
Most people don’t seek help because of stigma
o Say that the stigma is worse than the mental illness itself
o Stigma shows no differences between ages
One study could people 55-74 more likely to seek help than younger people for mental
Perceived need is the most important predictor of service use among older adults
o Less likely than young adults to perceive a need for mental health care they prefer
to handle their problems themselves
Need for education about therapy among older adults
o Men more stigma to psychotherapy then women
Older therapists may have negative views toward aging that affect the way they work
with OA
Need for practitioners to recognize how their own beliefs and views about aging may be
relevant to their assessment and treatment of older adults
Mental health literacy
o The knowledge and beliefs about mental disorders with aid in their recognition,
management and prevention
Integrative approaches that match the OA diagnosis are the most effective
Evidence based psychological practice
o Propose that clinicians integrate the best available research evidence and clinical
expertise in the context of the cultural background, preferences, and
characteristics of the client
 Must incorporate knowledge of age related physical, psychological and
social changes
Therapeutic alliances can help clinician work with older adults when they build trust
Psychodynamic therapy focuses on clients underlying conflicts but these traditional
models are changing and might look at other things like attachment style
Life review or reminiscence therapy
o Involves helping the older adult rework past experiences both pleasant and
unpleasant with the goal of gaining greater acceptance of the past
o Can have self-positive (problems solving), self-negative (bitterness), and
prosocial (teaching others) functions
o Self-positive reminiscence leads to increased wellbeing and self-negative worse
o Opportunity to reframe events that were once viewed negatively in a positive light
help the individual gain a sense of mastery over their life
Behavioural therapy
o Changing the reinforcements associated with the individual’s behaviour
o Based on the notions that client’s symptoms are due to a decrease in pleasant
events in lives associated with physical changes, loss of friends, and loss of
rewarding social roles
o Client tracks events that are positive reinforces and engage in more of them
Cognitive therapy
o Based on the theory that clients develop psychological disorders because they
have maladaptive thought processes
o People’s emotions follow their thoughts
o Help clients reframe their thoughts and develop more adaptive emotions
Cognitive behavioural therapy
o Encourage to develop more adaptive behaviours and ways of thinking of their
o Can be done in a variety of settings
- Interpersonal therapy
o Aimed at the social relationships
o Helps clients learn to understand and change their relationships with others
- Challenges with therapy and OA
o Greater probability of physical impairments that compromise the effectiveness of
therapy significant threat to quality of life
o Changes in identity associated with aging may stimulate need to for therapy
- Boosting OA sense of mastery can help them overcome physical limitations and
experience improvements in mood
- Social class should also be considered as OA from lower social class showed to be less
responsive to therapy
Serious Mental Illness:
- Significant amount of OA doesn’t experience significant distress
- OA are at higher risk in the objective sense for experience psych disorders
- Combinations of enhanced coping mechanisms, ability to maintain an optimistic attitude
toward adversity are protective factors against psych issues in OA
- OA are highly resilient to physical, cognitive and social changes involved in aging