Mental Health and Aging Notes
Introduction
By 2030, approximately 20% of the U.S. population will be 65 or older.
Increase in older adults with mental health issues is expected.
Important to study psychopathology in late life within lifespan development.
Differentiate between early-onset disorders persisting into older adulthood and late-onset disorders.
Psychopathology may manifest differently over time (heterotypic continuity).
Normal Development in Late Life
Characterized by stability and change in biological, cognitive, social, and emotional domains.
Biological aging: changes in the central nervous system and increased risk of physical illness.
Fluid intelligence declines with age; crystallized intelligence remains stable or improves.
Social changes: bereavement, retirement, caregiving; most older adults remain independent.
Selective Optimization and Compensation Model: aging is associated with narrowing opportunities (selection), enhancing abilities (optimization), and using alternative methods (compensation).
Socioemotional Selectivity Theory: social goals shift from information-oriented to emotion-oriented in late life.
Anxiety
Relatively common in late life.
Lifetime prevalence of any anxiety disorder is approximately 14.9% in adults aged 65 and older.
Specific phobias and social phobias are most common.
DSM-5 changes: removal of requirement of awareness of excessive anxiety for diagnoses of specific phobia, social phobia, and agoraphobia.
Description and Course:
Older adults report less frequent negative emotions and physiological arousal.
They may use exact language (e.g., "concerned" instead of "worried").
Phobias, panic attacks often co-occur with physical illnesses.
Older adults with GAD are more likely to worry about health.
Etiology:
Varies by anxiety disorder; can be rooted in conditioning.
Biological, psychological, and social factors increase vulnerability.
Explanation for Age Differences:
Frequent comorbid medical and psychiatric conditions complicate diagnosis.
Providers may mistakenly attribute anxiety symptoms to normal aging.
Emotion regulation skills may improve with age.
Assessment and Treatment:
Assessment is challenging due to diagnostic complexities.
Geriatric Anxiety Inventory and Geriatric Anxiety Scale are available.
Antidepressants and cognitive behavioral interventions are effective treatments.
Mood Disorders
Depression is a common and consequential disorder in late life.
Mood disorders include major depressive disorder, persistent depressive disorder, and bipolar disorder.
Depressive symptoms that do not meet mood disorder criteria are frequent and associated with adverse outcomes.
Major depressive disorder: characterized by pervasive dysphoria or anhedonia for at least 2 weeks, accompanied by additional symptoms.
Diagnostic criteria changes in DSM-5: depression following bereavement is no longer excluded from diagnosis.
Etiology:
Involves interplay between biological, psychological, and social vulnerabilities and stressors.
Reduction in meaningful and rewarding activities may lead to depression.
Explanation for Age Differences:
Diagnostic rubrics may not fully capture depression as manifested in old age.
Older adults are less likely to endorse dysphoria or anhedonia.
Assessment and Treatment:
Depression is underdetected in late life.
Cognitive behavioral therapy, problem-solving therapy, and reminiscence therapy are effective interventions.
Internet-delivered cognitive behavioral therapy is equally acceptable and effective.
Suicide
Older adults, particularly older men, have elevated rates of death by suicide.
Suicidal behavior: suicidal ideation, suicide attempts, and death by suicide.
Suicidal acts in late life are more likely to be fatal.
Etiology:
Interpersonal theory of suicide: interaction between desire to die and acquired capability for suicide.
Risk factors include depression, poor social support, dysfunctional coping strategies, and neurocognitive deficits.
Assessment and Prevention:
Interventions to reduce suicide include physician education and cognitive-behavior therapy.
Programs using social connectedness and peer companions are being tested.
Schizophrenia
Lifespan neurodevelopmental disorder; prevalence is lower in older adults.
Diagnostic criteria: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms.
Leading theories attribute etiology to genetic or biological vulnerability combined with environmental stressors.
Explanation for Age Differences:
Lower prevalence in late life may result from remission of the disease or selective mortality.
Late-onset schizophrenia refers to onset after age 40, and very-late-onset schizophrenia-like psychosis refers to onset after age 60.
Assessment and Treatment:
Antipsychotic medications are effective in controlling positive symptoms.
Cognitive behavioral social skills training improves social functioning.
Alcohol Use Disorders
Less common in late life but associated with severe health consequences.
DSM-5 diagnosis requires meeting two of 11 criteria, resulting in significant distress or impairment.
Some older adults start problem drinking after age 50, often in response to age-related stressors.
Etiology:
Arise from interaction of genetic risk and environmental factors.
Risk factors include pain, chronic medical conditions, sleep difficulties, and depression.
Explanations for Age Differences:
Excessive drinking declines with age; physiological changes may contribute to increased sensitivity to alcohol.
Alternative explanation is selective mortality.
Assessment and Treatment:
Accurate assessment is critical; underdetection and underreporting occur in primary care settings.
Elder-specific treatments are especially beneficial.
Hoarding
Hoarding disorder: persistent difficulty discarding possessions, accumulation of possessions cluttering living spaces, and significant distress or impairment.
Onset typically during adolescence; the course appears to be progressive and chronic across the lifespan.
Older adults who are socially isolated, never married, and have a history of childhood trauma are often more likely to hoard.
Epidemiology:
Hoarding is relatively common during late life, with prevalence rates estimated between 2% and 5%.
Associated with medication and dietary mismanagement, impairments in daily living, and premature relocation to senior housing.
Etiology:
Conceptualized as a result of information-processing deficits, beliefs about and emotional attachment to possessions, and avoidance behaviors.
Assesment and Treatment:
Hoarding problems often go undetected and untreated among older adults.
A newly developed behavioral treatment for compulsive hoarding disorder in older adults shows promise.
Personality Disorders
Pervasive and inflexible patterns of behavior associated with distress or impairment.
Antisocial Personality Disorder (ASPD) and Borderline Personality Disorder (BPD) are less prevalent.
Schizoid Personality Disorder (SPD) and Obsessive-Compulsive Personality Disorder (OCPD) appear to be more prevalent.
Etiology:
Can be conceptualized as maladaptive and extreme variants of normal personality traits.
The predisposition hypothesis suggests that middle-aged and older adults with personality disorders are more susceptible to age-related stressors.
Explanations for Age Differences:
The maturation hypothesis posits that immature personality types are more likely to improve with age.
Age differences may be reflective of biased diagnostic criteria; selective mortality may play a role.
Assessment and Treatment:
Assessment measures may be biased when used with older adults.
Course of treatment may be slowed, complicated, and possibly impeded compared with individuals without personality disorders.
Sleep Disorders
Older adults who suffer from sleep difficulties are at greater risk for falling.
Insomnia is both an independent DSM-5 diagnosis and a diagnostic component of many other psychological and psychiatric disorders.
Etiology:
The predominant conceptual model of insomnia is Spielman's behavioral model.
Changes in sleep structure that occur with normal aging may predispose older adults to insomnia.
Assessment and Treatment:
Assessment of insomnia often begins with complaints of trouble falling asleep, early awakening, or daytime fatigue.
Effective interventions include pharmacological treatment with hypnotics and behavioral techniques.
Dementia
Prevalence of dementia increases with age; more common among women than men.
Alzheimer's disease accounts for approximately 60-70% of all dementia cases.
DSM-5 diagnosis is now included under the newly named major neurocognitive disorder; DSM-5 also recognizes a less severe form of cognitive impairment, mild neurocognitive disorder.
Etiology:
Involves the progressive deterioration of the cerebral cortex and the hippocampus.
Risk factors include genetic vulnerability (APOE e4 allele), beta-amyloid plaques, and tangles of a protein called tau.
Explanations for Age Differences:
Risk for Alzheimer's disease increases directly with advancing age.
Aging-related conditions may play a role via damage to the vascular system.
Assessment and Treatment:
Assessment involves neuropsychological testing, somatic examination, and neuroimaging.
There are no published interventions for primary prevention; clinicians focus on preventive treatments of cardiovascular disease.
Psycholopathology In Late Life
There is evidence of both similarity and difference in psychopathology in late life relative to earlier ages.
Contrary to popular stereotype, late life is associated with lower prevalence of many types of psychopathology.
Biological changes associated with aging might explain also neurocognitive disorders.
Assessment can be challenging.
Older adults who do not manifest psychopathology in spite of risk factors could be particularly helpful in uncovering protective factors.