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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Serie: Understanding Aging
- Sprache: Englisch
Fully updated and revised, this new edition of a highly successful text provides students, clinicians, and academics with a thorough introduction to aging and mental health.
The third edition of Aging and Mental Health is filled with new updates and features, including the impact of the DSM-5 on diagnosis and treatment of older adults. Like its predecessors, it uses case examples to introduce readers to the field of aging and mental health. It also provides both a synopsis of basic gerontology needed for clinical work with older adults and an analysis of several facets of aging well.
Introductory chapters are followed by a series of chapters that describe the major theoretical models used to understand mental health and mental disorders among older adults. Following entries are devoted to the major forms of mental disorders in later life, with a focus on diagnosis, assessment, and treatment issues. Finally, the book focuses on the settings and contexts of professional mental health practice and on emerging policy issues that affect research and practice. This combination of theory and practice helps readers conceptualize mental health problems in later life and negotiate the complex decisions involved with the assessment and treatment of those problems.
- Features new material on important topics including positive mental health, hoarding disorder, chronic pain, housing, caregiving, and ethical and legal concerns
- Substantially revised and updated throughout, including reference to the DSM-5
- Offers chapter-end recommendations of websites for further information
- Includes discussion questions and critical thinking questions at the end of each chapter
Aging and Mental Health, Third Edition is an ideal text for advanced undergraduate and graduate students in psychology, for service providers in psychology, psychiatry, social work, and counseling, and for clinicians who are experienced mental health service providers but who have not had much experience working specifically with older adults and their families.
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Veröffentlichungsjahr: 2017
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Table of Contents
Cover
Title Page
Preface
Reference
Part I: Introduction
1 Mental Health and Aging
What Is Normal Aging?
What Is Abnormal or Unhealthy Aging?
Mental Health and Mental Disorder
Diagnostic and Statistical Manual of Mental Disorders (DSM‐5)
Linking the Physical and Mental in Later Life: Comorbidity
Individual Differences and Assessment of Risk
The Context of Clinicians and Clients: Now What Do We Do?
The Biopsychosocial Model
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
2 Basic Gerontology for Working with Older Adults
Developmental Issues in Mental Health and Aging
The Complexity of Working with Older Adults: Contexts, Cohorts, and Specific Challenges
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
3 Psychological Bases of Positive Mental Health
What do Models have to Account for?
Successful Aging
Selective Optimization with Compensation (SOC)
Resilience
Contributions from Psychological Science: Stereotype Threat and Positive Psychology
Are There Secrets to Aging Well?
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
Part II: Models of Mental Health in Later Life
4 Psychodynamic Model
Introduction to the Model
Adult Development: The Context for Aging
Development in the Second Half of Life
Mental Health in Later Life
Development of Psychopathology
Assessment
Treatment
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
5 Cognitive‐Behavioral Model
Introduction to the Model
Cognitive Aspects of the CBT Model
Behavioral Aspects of the CBT Model
Mental Health from the Cognitive‐Behavioral Model
Mental Health in Older Adults
Assessment
Treatment
Additional Comments about the Cognitive‐Behavioral Model
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
6 Stress and Coping Model
Introduction to the Model
Conceptualizing Coping
Stress and Coping: Normal and Abnormal Adaptation
Assessment Strategies
General Treatment Strategies and Health Psychology
Treatment Strategies
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
7 Family Systems Model
Introduction to the Model: Aging Families
Family Dynamics: A Systems Model
Mental Health within a Systems Model
Assessment
Intervention
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
Part II: Summary and Commentary
Part III: Introduction to Mental Disorders
8 Cognitive Impairment and Neurocognitive Disorders
Is Cognitive Impairment Normal for Older Adults?
Diagnostic Categories: A Time of Transition
Delirium: A Common, Reversible Cause of Cognitive Impairment
Mild Cognitive Impairment and Mild NCD
Major Neurocognitive Disorders
Depression and Cognitive Impairment
Summary of the Types of Cognitive Impairment
Assessment
Interventions
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
9 Major Depression and Bipolar Disorder
Definition of Depression
Prevalence of Depression in Older Adults
Theories of Etiology
Vascular Depression and its Link to Dementia
Assessment
Interventions
Prevention of Depression
Suicide
Bipolar Disorder
Prevalence of Bipolar Disorder in Older Adults
Etiology, Assessment, and Interventions
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
10 Serious Mental Disorders in Older Adults
Overview of Schizophrenia Throughout the Lifespan
Distinguishing Schizophrenia from Other Psychotic Disorders
Differences in the Onset, Course, and Outcome of Schizophrenia
Factors Complicating the Course and Outcomes of Schizophrenia
The Aging Person with Schizophrenia: Early‐Onset Schizophrenia (EOS)
The Aging Person with Schizophrenia: Late‐Onset Schizophrenia (LOS)
Future Directions and Opportunities
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
11 Anxiety Disorders, Hoarding Disorder, and Post‐Traumatic Stress Disorder
Anxiety
Hoarding Disorder
Post‐Traumatic Stress Disorder (PTSD)
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
12 Sexual Disorders, Sleep Disorders, and Chronic Pain
Sexual Disorders
Sleep Disorders
Chronic Pain
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
13 Substance‐Related Disorders and Personality Disorders
Substance‐Related Disorders
Prevalence
Presentation in Older Adults
Theories of Etiology
Assessment of Substance Use and Abuse
Interventions for Substance Abuse
Personality Disorders
Prevalence
Presentation in Older Adults
Theories of Etiology
Assessment of Personality Disorders
Interventions for Personality Disorders
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
Part IV: Settings and Contexts of Mental Health
14 Health Services Delivery Systems
Health Service Delivery Systems 101
Mental Health Services Industry
Looking to the Future: Integration of Health Services
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
15 Housing, Social Services, and Mental Health
Person–Environment Fit: A Key Principle That Shapes Housing Choices and Challenges
The Continuum of Senior Housing
Social Services
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
16 Family and Friend Relationships, and Caregiving
Social Networks in Later Life
Family Caregiving Relationships and Mental Health
Interventions to Assist Families
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
17 Ethical Issues in Work with Older Adults
Advanced Illness and Advanced Care Directives
Financial Fraud and Abuse
Aging and Climate Change: Another Context for Concern
Inequality and Issues of Justice
Summary and Conclusions
Critical Thinking / Discussion Questions
Website Resources
References
Epilogue
Index
End User License Agreement
List of Tables
Chapter 02
Table 2.1 A balance sheet of losses and gains in later life
Table 2.2 An overview of individual, cohort, and contextual elements affecting assessment and psychotherapy with older adults
Chapter 03
Table 3.1 Percentage of sample successfully aging
Chapter 04
Table 4.1 Psychodynamic model of adult development
Table 4.2 Schematic table of adaptive mechanisms
Chapter 06
Table 6.1 COPE clusters, specific scale definitions, and sample items
Table 6.2 WCQ factors, definitions, and sample items
Chapter 08
Table 8.1 Diagnostic features of delirium
Chapter 09
Table 9.1 Diagnostic features for major depressive disorder and persistent depressive disorder (dysthymic disorder)
Table 9.2 Medical conditions and medications associated with depression
Table 9.3 Social antecedents of depression
Table 9.4 Key risk and protective factors for suicide among older adults
Chapter 10
Table 10.1 Integrated medical and psychiatric modules in Integrated Illness Management and Recovery (I‐IMR)
Chapter 11
Table 11.1 Diagnostic features for anxiety disorders
Table 11.2 Diagnostic features for Post‐Traumatic Stress Disorder
Chapter 12
Table 12.1 The sexual response cycle
Table 12.2 Major sleep–wake disorders in the DSM‐5
Table 12.3 Basic assumptions of the cognitive‐behavioral model of pain
Chapter 13
Table 13.1 Prescription medications used in past 30 days, among older adults
Table 13.2 Michigan Alcoholism Screening Test—Geriatric Version (MAST‐G)
Table 13.3 Description of the 10 DSM‐5 personality disorders and four personality disorders from prior editions of the DSM
Table 13.4 Theorized patterns or geriatric variants for the personality disorders in later life
Chapter 15
Table 15.1 Activities of daily living
Table 15.2 Funding for the Titles of the Older Americans Act (2012)
Chapter 17
Table 17.1 Resources for starting the conversation about advanced care
Table 17.2 Comprehensive advanced care planning tools
Part 02-01
Table S1.1 Choosing among models
List of Illustrations
Chapter 01
Figure 1.1 Frequent mental distress by age group in 2010 (% of respondents).
Figure 1.2 Lifetime prevalence of DSM‐IV/World Mental Health Survey disorders by age group in the United States from the National Comorbidity Survey Replication sample.
Figure 1.3 Percentage of respondents reporting that they have a chronic health problem stratified by age and socioeconomic status (SES).
Figure 1.4 Suicide death rates per 100,000 people, ages 5 to 85+ for 2014 in the US.
Figure 1.5 Graphical representation of the biopsychosocial model of mental disorders.
Chapter 02
Figure 2.1 Percentage of population aged 65 years and older by major world region, 2015 and projected 2050.
Figure 2.2 Cross‐sectional age differences in the primary mental abilities.
Figure 2.3 Estimated age changes in the primary mental abilities.
Note:
“Other” in race includes the categories of American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, some other race, and two or more races.
Figure 2.4 Percentage of United States population aged 65 and over with a disability by race.
Chapter 03
Figure 3.1 The relationship among objective success, subjective success, and indicators.
Figure 3.2 Resilience and aging.
Chapter 04
Figure 4.1 Psychosocial themes and stages of life.
Chapter 05
Figure 5.1 The reciprocal nature of thoughts, feelings, and behaviors in the CBT model.
Figure 5.2 Geriatric Depression Scale responses for Joanna Jenkins (baseline).
Figure 5.3 Geriatric Depression Scale total scores for Joanna Jenkins across sessions.
Figure 5.4 Record of questioning behavior by Anna Tweed.
Figure 5.5 Daily Mood Rating Form for Joanna Jenkins.
Figure 5.6 Older Person’s Pleasant Events Schedule completed by Joanna Jenkins.
Figure 5.7 Daily Thought Record for Joanna Jenkins.
Chapter 06
Figure 6.1 Central role of the brain in the protective and damaging effects of the mediators of stress and adaptation.
Figure 6.2 Multilevel model of contributors to stress.
Chapter 07
Figure 7.1 Genogram depicting Jason Martinez’s family.
Figure 7.2 Family stages and events.
Chapter 08
Figure 8.1 Conceptual hierarchy of cognitive functions.
Figure 8.2 Continuum of family roles for childrearing and caregiving.
Figure 8.3 Relationship between environmental press, competency, and well‐being.
Chapter 09
Figure 9.1 DSM‐IV major depressive episode 30‐day, 12‐month, and lifetime prevalence estimates by age.
Chapter 11
Figure 11.1 Past‐year prevalence of DSM‐IV anxiety disorders by gender and age among 12,312 US adults aged 55 years and older.
Note
: PTSD was removed from the anxiety disorders category in DSM‐5 and placed into a new category called Trauma‐ and Stressor‐Related Disorders.
Chapter 12
Figure 12.1 Persistent pain reported in the US by age group and gender from the 2010 National Health Interview Survey.
Chapter 13
Figure 13.1 Number of people in the United States aged 12 or older with a past‐year substance use disorder in 2014 by disorder.
Note
: People may be diagnosed with more than one disorder.
Chapter 15
Figure 15.1 Percentage of long‐term‐care services users by sector and activity, in the US 2013 and 2014.
Figure 15.2 Percentage of long‐term services care users across sectors, in the US 2013 and 2014.
Chapter 16
Figure 16.1 Social network circles.
Figure 16.2 Stages of family caregiving.
Figure 16.3 Caregiver Family Therapy components.
Chapter 17
Figure 17.1 The impact of climate change on physical, mental, and community health.
Guide
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Praise for Aging and Mental Health
“Aging and Mental Health is that rare book which is both pleasurable to read and deeply informative. The science of psychiatric diagnosis and treatment is set forth through rich conceptual frameworks of gerontology and psychology, and – new in this edition – critical health service contexts. As a comprehensive and skillfully crafted resource all in one volume, the book is an indispensable gem for students and practitioners alike.”
Jennifer Moye, PhD, VA Boston Healthcare System and Harvard Medical School
“The Third Edition of Aging and Mental Health offers far more than an update. It is a thoughtfully and creatively designed textbook poised to serve as a strong introduction to major clinical disorders, dominant models of therapy, service delivery systems, and ethical issues, together rounding out the universe of mental health and mental illness in older adults. Generous and well‐selected references for each topic are provided.”
Erlene Rosowsky, PsyD, Director of the Center for Mental Health and Aging and Associate Professor of Psychology, William James College
“Kudos to the authors of this updated new edition on Aging and Mental Health. Life span developmental theory, normative biopsychosocial processes, and models of successful aging inform clinical recommendations for mental health professionals who provide services to older adults. This is an excellent volume to read and reference if one desires to employ an evidence‐based state‐of‐the art approach to assess and treat the mental health problems of older adults and to promote integrated care in geriatric settings.”
Victor Molinari, PhD, President of the American Board of Geropsychology and Professor, School of Aging Studies, University of South Florida
“I’ve used Aging and Mental Health as a textbook for my undergraduate class in “Gerontological Counseling” and my graduate class in “Aging and Mental Disorders” for a decade. This book is unique in including reviews of fundamental issues in gerontology (e.g. age‐related changes), major theoretical models of mental health, the most common mental disorders of late life, and contextual issues such as policy, housing, and caregiving issues. The text is full of vivid case studies and practical information. The Third Edition includes valuable updates, such as incorporation of the DSM‐5 and recent research information. The authors bring years of experience in clinical practice, research, and public policy related to mental health to bear on the topic. This is the perfect text for instructors from diverse fields who want to engage their students in understanding mental health and aging, and help them develop a passion for providing excellent care for older adults and their families.”
William E. Haley, PhD, Professor, School of Aging Studies, University of South Florida
UNDERSTANDING AGING
The Psychology of Adult Development
General EditorJames E. Birren
Editorial Advisory BoardStig Berg, Dennis Bromely, Denise Park, Timothy A Salthouse, K Warner Schaie, and Diana Woodruff‐Pak
During this century, life expectancy at birth has increased more for the average person than it did from Roman times to 1900: There are a greater number of old people today and they live longer than ever before. Within universities there is pressure to educate younger students about the scientific facts of adult development and aging as well as to train professionals to serve and aging society. The past 20 years have seen an exponential growth in material published.
This new series of modular texts has been designed to meet the need to integrate, interpret, and make this new knowledge available in an efficient and flexible format for instructors, students, and professionals worldwide. Each book will present a concise, authoritative, integrated and readable summary of research and theory in a clearly defined area. Bridging the gap between introductory texts and research literature, these books will provide balanced coverage and convey the excitement and challenge of new research and developments. The modular format allows the series to be used as a complete sequence in primary courses in other fields.
Published
The Social Psychology of Aging by Michael W. Pratt and Joan E. Norris
The Neuropsychology of Aging by Diana S. Woodruff‐Pak
Aging and Mental Health, Second Edition by Daniel L. Segal, Sara Honn Qualls, and Michael A. Smyer
Aging and Mental HealthThird Edition
Daniel L. Segal, Sara Honn Qualls, and Michael A. Smyer
This edition first published 2018© 2018 John Wiley & Sons, Inc.
Edition HistoryWB ‐ Wiley‐Blackwell (2e, 2011)Blackwell Publishers (1e, 1999)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Daniel L. Segal, Sara Honn Qualls, and Michael A. Smyer to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
Registered Office(s)John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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Library of Congress Cataloging‐in‐Publication Data
Names: Segal, Daniel L., author. | Qualls, Sara Honn, author. | Smyer, Michael A., author.Title: Aging and mental health / by Daniel L. Segal, University of Colorado at Colorado Springs, Colorado Springs, CO, US 80918, Sara Honn Qualls, University of Colorado at Colorado Springs, Colorado Springs, CO, US 80918, Michael A. Smyer, Bucknell University, Lewisburg, PA, US, 17837.Description: 3rd edition. | Hoboken, NJ: Wiley, 2018. | Includes bibliographical references and index. |Identifiers: LCCN 2017034907 (print) | LCCN 2017035874 (ebook) | ISBN 9781119133162 (pdf) | ISBN 9781119133155 (epub) | ISBN 9781119133131 (pbk.)Subjects: LCSH: Older people–Mental health. | Geriatric psychiatry.Classification: LCC RC451.4.A5 (ebook) | LCC RC451.4.A5 S66 2018 (print) | DDC 618.97/689–dc23LC record available at https://lccn.loc.gov/2017034907
Cover image: Courtesy of Michael A. SmyerCover design: Wiley
Daniel L. Segal: To the memory of my grandparents (Samuel and Tess Segal, and Norman and Harriet Golub) whom I loved very much and miss dearly
Sara H. Qualls: To my children and the students at UCCS from whom I learn much
Michael A. Smyer: To four generations of the Pipers
Preface
What is important in knowledge is not quantity, but quality. It is important to know what knowledge is significant, what is less so, and what is trivial.
(Leo Tolstoy)
In this book, we have endeavored to take Tolstoy’s maxim to heart, sorting out the significant from the trivial in the domain of aging and mental health. As we did so, we had two audiences in mind: today’s clinicians and the clinicians of the future. The first group includes clinicians who are already in practice settings but who want to know more about the intricacies of working with older adults. The second group encompasses students in the professions that work with older adults (e.g., psychology, social work, counseling, nursing, psychiatry).
Both groups must face the issues of aging summarized by Michel Philibert, a French philosopher: “Of aging, what can we know? With aging, what must we do?” (Philibert, 1979, p. 384). These are also issues that older adults and their family members must face. In a way, they are variations on the questions that often arise in clinical settings. Consider the following example:
Betty was worried about Alex. His memory seemed to be failing him more often. He would get to the store and forget half of the things she’d sent him there for. He seemed more tired than usual, with less energy for his hobbies at the end of the day or on weekends. He didn’t want to go out with friends to the movies or to dinner. Alex didn’t seem to notice anything different in his behavior. Betty called to ask your advice: “Should I get him tested at the local Alzheimer’s Center?”
How would you answer Betty? What would you need to know? Which portion of her story is significant in forming your answer? Which less so? In answering these questions, you are implicitly answering Philibert’s queries as well. You are implicitly making a differential diagnosis of Alex’s situation: Is this a part of normal aging? Is this a pathological pattern? Is it a combination of the two? (Of aging, what can we know?) You may also be linking your answer to an implicit action plan. Betty certainly is: Diagnose the problem and then decide what kind of treatment is most appropriate. (With aging, what must we do?)
To fully answer Betty’s question requires much more information about aging in general, about patterns of mental health and mental disorder in particular, about Alex’s distinctive history and pattern of functioning, and about the contexts in which she and Alex live and receive services. We designed this book to provide you with frameworks for considering each element.
The book is divided into four parts. Part I is an overview of basic gerontology, the study of the aging process. This background information forms a context for answering the simple question often posed by clients and their relatives: Should I be worried about this pattern of behavior (e.g., Alex’s apparent memory problems)? To answer this deceptively simple question requires that we sort out the influences of physical illness, basic processes of aging, and the intersection of historical and social trends as they affect older adults’ functioning. In Part I, we outline the basic parameters of mental health in later life, providing the foundation upon which later chapters build.
In Part II, we consider basic models of mental disorders. Each model provides a set of assumptions about mental health and the development of mental health problems, their assessment, and their treatment. These assumptions direct the clinician’s attention to specific aspects of older adults and their functioning. For example, assume for the moment that Alex’s memory problems are not organically caused. The behavioral perspective might highlight the context of the older adult’s behavior. Four important models of mental health and mental disorder are outlined in the chapters of Part II. In each chapter, we focus on an important question for older adults and those who work with them: How is this approach relevant to older adults and the problems they encounter in later life?
Part III focuses attention on the most commonly occurring mental health problems and disorders in later life: neurocognitive disorders, major depression, bipolar disorder, serious mental disorders (e.g., schizophrenia), anxiety disorders, post‐traumatic stress disorder, sexual disorders, sleep disorders, substance use, personality disorders, and other common disorders. In each chapter, we outline the prevalence of the disorders, the most appropriate assessment approaches for older adults, and the most effective treatment strategies for older adults. We were fortunate to be able to call upon Stephen J. Bartels and his colleagues for their expertise in the diagnosis and treatment of severe mental disorders (Chapter 10).
Part IV concludes our book with several chapters focusing on the contexts and settings of contemporary geriatric mental health practice. The contexts of housing, health care settings, social service settings, and public policy affect how, where, and why older adults with mental health problems are diagnosed and treated. Families and caregiving are also addressed, as families are the primary providers of care, and caregiving is a challenge facing millions of people who are taking care of older family members and friends who need assistance. This section concludes with an analysis of ethical and legal issues facing practitioners in geropsychology and also discusses the impact of global climate change.
Colleagues and friends in several settings have helped us write this book: in the Department of Psychology, the Aging Center, and the Gerontology Center of the University of Colorado at Colorado Springs, and in the Center for Advanced Study in the Behavioral Sciences at Stanford University. We thank Brian P. Yochim and Mary Dozier for their feedback on specific chapters of the book, and we thank Lacey Edwards for her contributions to Chapter 4. We also thank Michelle Buffie for her expertise in making figures and tables. Early in the development of the first edition we benefited from the guidance and advice of Jim Birren and two anonymous reviewers. The process of revision for the second edition was supported by input and advice from our academic and community services colleagues as well as a new set of anonymous reviewers. We eagerly acknowledge our debt to each, while also admitting that any remaining flaws are ours. We also express our deepest appreciation to our friends and editors at Wiley, including Darren Reed, Monica Rogers, Roshna Mohan, Catherine Joseph, Elisha Benjamin, and Nishantini Amir, and our excellent copy‐editor Katherine Carr, whose patience and diligence ensured that this third edition came to fruition. Finally, we remain grateful to our family members and friends for their ongoing love, encouragement, and support.
Our goal throughout this book is to provide information and a set of frameworks that will be useful in working with older adults and their families. In the end, we hope that you will conclude that there is much to hope for in aging, and much that we can do to foster positive mental health later in life.
Reference
Philibert, M. (1979). Philosophical approach to gerontology. In J. Hendricks & C. Davis Hendricks (Eds.),
Dimensions of aging
(pp. 379–394). Cambridge, MA: Winthrop.
Part IIntroduction
1Mental Health and AgingAn Introduction
Consider the following case description:
Grace, director of a Senior Center in your area, calls you about Mr. Tucker. Although Mr. Tucker used to come to the center three or four times a week, he hasn’t come at all since the death of his good friend, Ed, four months ago. Grace had called Mr. Tucker at home to say how much he’d been missed. When she asked if he wasn’t coming because he was still upset over Ed’s death, he denied it. Instead, Mr. Tucker said that he wanted to return to the center, but he was in terrible pain. In fact, he was in so much pain that he really couldn’t talk on the phone and he abruptly hung up. Grace was worried that Mr. Tucker might not be getting the medical attention that he really needed. She asked you to make a home visit, which you agreed to do. You call Mr. Tucker and set up an appointment.
As you prepare to visit Mr. Tucker, what are the basic questions you might ask about him and his situation? Which factors do you think are important to explore with Mr. Tucker? How would you assess Mr. Tucker’s functioning?
Your answer to these simple inquiries reflects your implicit model of mental health and aging. In this book, especially in Part II, we will illustrate several different conceptual models of mental disorders and aging. In doing so, we will emphasize the links between one’s starting assumptions and one’s subsequent strategies for assessment and intervention. You will come to see that your philosophical assumptions about mental health, mental disorder, and aging shape the interpretive process of working with older adults and their families.
Mr. Tucker’s current functioning raises a basic question: Is his behavior simply part of normal aging or does it represent a problem that requires professional attention? Our answer represents implicit and explicit assumptions regarding the continuum of functioning that runs from outstanding functioning through usual aging to pathological patterns of behavior.
What Is Normal Aging?
The starting point for mental health and aging must be a general understanding of gerontology, the multidisciplinary study of normal aging, and geriatrics, the study of the medical aspects of old age and the prevention and treatment of the diseases of aging. In Mr. Tucker’s case, we want to know if his reaction is a part of a normal grieving process or an indication of an underlying mental health disorder (e.g., a mood disorder, such as major depressive disorder). To answer this requires a starting definition of normal aging.
A conceptual definition
Discussions of this issue focus attention on three different patterns of aging: normal or usual aging, optimal or successful aging, and pathological aging. Baltes and Baltes (1990) provided classic definitions of normal and optimal aging:
Normal aging refers to aging without biological or mental pathology. It thus concerns the aging process that is dominant within a society for persons who are not suffering from a manifest illness. Optimal aging refers to a kind of utopia, namely, aging under development‐enhancing and age‐friendly environmental conditions. Finally, sick or pathological aging characterizes an aging process determined by medical etiology and syndromes of illness. A classical example is dementia of the Alzheimer type. (pp. 7–8)
Schaie (2016) provides a somewhat different conceptual perspective of the possible trajectories of aging, distinguishing four major patterns. Normal aging is the most common pattern, characterized by individuals maintaining a plateau of psychological functioning through their late 50s and early 60s and then showing modest declines in cognitive functioning through their early 80s, with more dramatic deterioration in the years before death. In contrast, successful agers are characterized by being genetically and socioeconomically advantaged, and maintaining overall cognitive vitality until right before their death. As described by Schaie, “These are the fortunate individuals whose active life expectancy comes very close to their actual life expectancy” (p. 5). The third pattern includes those who develop mild cognitive impairment. Individuals in this group experience declines in cognitive functioning that are more severe than is typical. Some, but not all, in this group progress to having more substantial cognitive problems. Finally, the fourth pattern is those who develop dementia, in which individuals experience severe, dramatic, and diagnosable forms of cognitive impairments. (We fully discuss the dementias and neurocognitive disorders in Chapter 8).
A statistical definition
Distinguishing between normal aging and optimal aging requires us to sort out statistical fact from theoretically desirable conditions. For example, the Baltes and Baltes definition suggests that normal aging does not include “manifest illness.” However, in the United States today, chronic disease is typical of the experience of aging: More than 25% of all adults and 66% of older Americans have multiple chronic conditions. This is an expensive issue: More than two‐thirds of all health care costs in the US are for treating chronic illnesses. For older adults specifically, 95% of health care costs are for chronic diseases (Centers for Disease Control and Prevention, 2013).
Let’s look at a specific condition: arthritis. Current estimates indicate that 22.7% of adults in the US reported having doctor‐diagnosed arthritis, including 49.7% of people 65 years old and older (Barbour et al., 2013). Moreover, among the oldest old groups (75+ or 85+) there are substantially higher rates. Thus, from a statistical perspective, arthritis is certainly modal, and may be considered a part of normal aging. We will return to this theme in Chapter 2.
A functional definition
Another approach to defining normal aging arises from defining “manifest illness.” By focusing not on presence or absence of a chronic disease, such as arthritis, but on the impact of that disease, we may get another depiction of “normal aging.” Here, again, though, the definition of terms can affect our conclusions regarding normal aging.
Consider the prevalence of disability among older adults. Functional disability could be considered one indicator of manifest illness among older adults. So far, so good. However, how shall we define functional disability? The answer may determine our conclusion about what is or is not normal for later life. Again, Mr. Tucker’s situation may help us clarify the issues:
When you get to Mr. Tucker’s house, you find an apathetic, listless, very thin man of 81. He seems to be isolated socially, having few friends and even fewer family members in the area. (He never married and he has no living siblings.) Although he seems physically able to cook, he says that he hasn’t been eating (or sleeping) regularly for quite a while—and he doesn’t care if he never does again.
Is Mr. Tucker functionally disabled? If so, is this normal for someone of his age? According to the US Census Bureau, most persons aged 75 years old and older have a disability: 54% of those 75–79 years old had any type of disability with 38% having a “severe disability” (Brault, 2012). In contrast, Manton, Gu, and Lamb (2006) reported that 78% of the 75–84 age group was “non‐disabled.” How could such differing pictures of older adults emerge?
The answer lies in the definition of disability. The Census Bureau focuses on difficulty with functional activity for its specific definition of disability. The range of functional activities is somewhat broader than traditional definitions: lifting and carrying a weight as heavy as 10 pounds, walking three city blocks, seeing the words and letters in ordinary newsprint, hearing what is said in normal conversation with another person, having one’s speech understood, and climbing a flight of stairs. In contrast, Manton et al. (2006) focused on activities of daily living (ADLs; e.g., taking care of basic hygiene, eating, getting dressed, using a toilet) and instrumental activities of daily living (IADLs; e.g., managing money, doing the laundry; preparing meals; shopping for groceries).
Not surprisingly, these different definitions of disability produce different depictions of functioning and normal aging. The metric we use in assessing functional ability is important for two reasons: The specific activities may be important in and of themselves; and one’s ability to complete activities (such as ADLs and IADLs) acts as a proxy for underlying physical, cognitive, emotional, and social abilities. Thus, depending upon the range of functioning we wish to assess, we may conclude that Mr. Tucker is either disabled or not and that such a pattern of functioning is either normal or unusual aging!
What Is Abnormal or Unhealthy Aging?
Thus far, we have considered merely one side of the dilemma: What is normal aging? We have also limited ourselves to physical and functional definitions, steering clear of similar issues focusing on mental health problems or disorders.
You notice that Mr. Tucker doesn’t mention being in any terrible pain—that is until you mention his friend Ed. When you do, Mr. Tucker grabs his side and says how much it hurts to talk. You suggest that he lie down and rest for a minute, which he does.
From the couch, Mr. Tucker begins to talk about Ed. It turns out that the two men were not just “friends” as Grace had implied. They were like brothers (if not closer) and had been since they were boys. “I’m good for two things,” Mr. Tucker said, “no good and good for nothing. But Ed was my buddy anyway. Don’t know why he bothered with me. I never made much of my life. But I do know that it won’t be hunting season without him. Just can’t do it alone and nobody in their right mind would want to hunt with an old fool like me.”
Again, the presentation and responses of Mr. Tucker challenge us. Does he have a mental disorder? The answer depends upon resolving other issues: How will we define mental health among older adults? Conversely, how will we define mental disorder among older adults? In Part III of this book, we will discuss assessment and treatment approaches for many specific mental disorders. Here, however, we start at the beginning: definitions of mental health and mental disorder.
Mental Health and Mental Disorder
The Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors (2008) thoughtfully summarized the importance of mental health in later life:
The World Health Organization defines health as “a state of complete physical, mental, and social well‐being and not merely the absence of disease or infirmity.” Because mental health is essential to overall health and well‐being, it must be recognized and treated in all Americans, including older adults, with the same urgency as physical health.
Indeed, in the past two decades mental health has become more integrated into the larger public health mission. As an example, the mental health of older Americans was identified as a priority by the Healthy People 2020 objectives (US Department of Health and Human Services, 2010) and more recently by the 2015 White House Conference on Aging (US Department of Health and Human Services, 2015).
Mental health among older adults is a multifaceted concept that reflects a range of clinical and research activity, rather than a unified theoretical entity (Qualls & Layton, 2010; Qualls & Smyer, 1995). Definitions of mental health in later life combine several complex elements: statistical normality, the link between individual functioning and group norms, the extent to which specific disorders can be effectively treated or controlled, and ideals of positive functioning.
Diagnostic and Statistical Manual of Mental Disorders (DSM‐5)
In contrast to definitions of mental health, there is greater agreement on definitions of mental disorder (for all age groups, including older adults). For both clinical and research purposes, operational definitions of mental disorder usually follow the guidelines in the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM‐5; American Psychiatric Association, 2013). The DSM‐5 is the standard classification of mental disorders used by mental health professionals in the United States. The DSM‐5 defines several hundred distinct mental disorders and lists the specific diagnostic criteria for each disorder, as well as other information such as the impact of gender, culture, and aging on the expression of the disorders. Thus, mental disorder in older adults is operationally defined by patterns of disorders in the DSM‐5.
A notable feature of the DSM system is that it uses a categorical approach to the classification of mental disorders. In other words, mental disorders are conceptualized as either being present (the diagnostic threshold is reached for an individual) or absent (the threshold was not reached). This follows the prominent model in medicine in which one either has a disorder (e.g., cancer) or one does not. In actuality, it is clear that mental disorders are best represented using a dimensional approach in which the severity of any specific disorder can be rated along a continuum from absent or mild to the most severe expression. This is the approach we endorse, to think dimensionally about mental disorders rather than categorically.
Earlier editions of the DSM (the first edition was published in 1952) used Roman numerals to identify new editions (e.g., DSM‐II, DSM‐III, and DSM‐IV). However, with publication of DSM‐5, the switch was made to Arabic numerals. This change is a true reflection of the current digital age in which we now live. The premise is that minor updates to the DSM can be disseminated more regularly, using sequential annotations of DSM‐5.1, DSM‐5.2, and so on until a full new edition is eventually published (to be called DSM‐6). Although the DSM‐5 is arguably the most comprehensive and sophisticated version yet developed, it is still a human‐made system that is limited by our current scientific understanding of mental disorders. In our opinion, the DSM‐5 is best viewed as a tool to be used by clinicians and researchers, not as a definitive manifesto that is above reproach and without criticism (for a discussion of some criticisms and limitations of the DSM; see Segal, Marty, & Coolidge, 2017).
The DSM‐5 is often used in conjunction with the International Statistical Classification of Diseases and Related Health Problems (ICD, now in its 10th edition), produced by the World Health Organization (WHO). The ICD is a more broad and comprehensive manual that includes physical health as well as mental health disorders, and it is more widely used than the DSM‐5 in Europe and other parts of the world. However, regarding mental disorders, the two manuals are highly compatible due to recent and ongoing efforts in the revision process of both systems to harmonize one with the other. In fact, with the passage of the Patient Protection and Affordable Care Act of 2010 in the US, as of October 2015, ICD‐10 codes for mental disorders were required for all coding and billing purposes to insurance companies. Fortunately the DSM‐5 provides a table that gives ICD‐10 codes for all DSM‐5 disorders to assist with this transition. For organizational purposes of this book, we will use the DSM‐5 categorization of mental disorders throughout because the DSM‐5 is still the prominent diagnostic system in the US. It helps to know that the DSM is highly aligned with the ICD.
Now that we have defined mental health and mental disorder, let’s take a look at how these play out among older adults in the US. The Centers for Disease Control’s Behavioral Risk Factor Surveillance System (BRFSS) is a large interview project that assesses general mental health status in the US. Respondents are asked to report how many of the previous 30 days their mental health was not good because of stress, depression, or problems with emotions. Frequent mental distress is defined as having 14 or more mentally unhealthy days in the previous 30 days. In 2010, only 7.4% of adults aged 65–74 reported frequent mental distress and the percentage was slightly lower (6.3%) for the 75 years or older group (CDC, 2010). Older adults clearly had the lowest rates of frequent mental distress compared to the younger age groups (see Figure 1.1).
Figure 1.1 Frequent mental distress by age group in 2010 (% of respondents).
Source: Adapted from the Centers for Disease Control (2010).
A similar pattern emerges when the focus is on diagnosed mental disorders. The National Comorbidity Survey Replication (NCS‐R, 2007) includes interviews about mental disorders from a large, nationally representative sample in the US. Again, older adults had lower levels of diagnosable anxiety disorders, mood disorders, impulse control disorders, and substance use disorders compared to younger adult groups (see Figure 1.2).
Figure 1.2 Lifetime prevalence of DSM‐IV/World Mental Health Survey disorders by age group in the United States from the National Comorbidity Survey Replication sample.
Source: Adapted from the National Comorbidity Survey Replication (2007).
Depression is clearly not a part of normal aging. And, in the vast majority of cases, depression is a treatable condition, with several effective biological and psychotherapeutic approaches (Fiske, Wetherell, & Gatz, 2009). However, geriatric depression reflects the difficulty of discerning “normal aging” from pathological aging. Depression in later life appears in several guises. Depression can easily be confused with medical problems, cognitive impairment, variations in the grief process, and the normal ups and downs of later life. Only around 5.0% of adults aged 65 years or older currently have depression and 10.5% have had a lifetime diagnosis of depression (Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors, 2008). However, the prevalence of depressive symptoms among older adults is much higher. (See Chapter 9 for a full discussion of the epidemiology of depression.)
Again, the challenge is distinguishing between normal and pathological aging: Are Mr. Tucker’s sleep and appetite disturbances a sign of depression, a part of the normal aging process, or a combination of the two?
Another challenge is that rates of mental disorders vary by setting. For example, older adults in institutional settings present a very different picture. Grabowski, Aschbrenner, Feng, and Mor (2009) analyzed data from Minimum Data Set assessments and found that 27% of newly admitted nursing home residents were diagnosed with schizophrenia, bipolar disorder, depression, or an anxiety disorder. These researchers summarized the impact of these patterns: “Nursing homes have become the de facto mental health care institution as a result of the dramatic downsizing and closure of state psychiatric hospitals, spurred on by the deinstitutionalization movement” (p. 689). Sadly, this situation does not appear to be getting better, and recent data suggest that as the proportion of nursing home residents with serious mental disorders increases, the quality of care for all residents decreases (Rahman, Grabowski, Intrator, Cai, & Mor, 2013).
A final relevant issue is not simply the rates of mental disorder in older adults, but rather the pattern of the age of onset of mental disorders (e.g., the average age at which people tend to first experience the disorder). Informative data from the NCS‐R indicate that the median age of onset was much earlier for anxiety disorders (11 years old) and impulse‐control disorders (11 years old) than for substance use disorders (20 years old) and mood disorders (30 years old). For all of the mental disorders included in this large study, 50% of all lifetime cases start by age 14, 75% of all lifetime cases start by age 24, and 90% of all lifetime cases start by age 42 (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005). Thus, the first onset of most mental disorders is in childhood or adolescence and a much smaller percentage of disorders have an onset in later life. Among older adults with a mental disorder, it is clinically relevant to determine when the disorder began. For example, an older adult who has suffered from lifelong depression will likely have a lengthier and more complicated treatment than an older adult who experienced depression for the first time in later life. The issue of age of onset is further explored in many of the chapters on specific mental disorders in Part III of this book.
Linking the Physical and Mental in Later Life: Comorbidity
Mr. Tucker’s pattern of symptoms—his lethargy, social withdrawal, and his reported physical pain—remind us of the importance of comorbidity: combinations of more than one mental disorder, physical illness, or combination of both. In a classic paper, gerontologist Gene Cohen (1992) provided a context for understanding comorbidity by outlining four useful paradigms for the interaction of physical and mental well‐being among older adults:
Psychogenic (or psychologically based) stress may lead to health problems.
Health problems may lead to psychiatric disturbances.
Coexisting mental and physical health problems may interact.
Social and psychosocial resources may affect the course of physical or mental disorders.
Indeed, one’s initial concern about a client or patient may be raised by seeing evidence of either a physical or mental health problem.
First, psychogenic stress may lead to physical health problems. In Mr. Tucker’s case, abdominal pain may be a reaction to his grief over Ed’s death. For Mr. Tucker, this physical symptom may be a more socially acceptable way for him to express his emotional pain. More generally, you are likely well aware of the strong connection between the mind and the body. You may have noticed in yourself or others times when stress from the environment affected you physically, for example through headaches, stomach upset, or teeth grinding.
Second, the direction of causality may be reversed, however, with a physical disorder leading to psychiatric problem. Consider the following sentence:
The five senses tend to decline with senescence.
Remove the f’s, s’s, c’s and th’s. Now try to make sense of what’s left:
e ive en e tend to de line wi ene en e.
This example mimics high‐frequency hearing loss among older adults and gives you a sense of how easily such a hearing loss might lead to delusions and confusion among this age group.
A third possibility is that coexisting physical and mental disorders may interact. One category of mental disorders among older adults underscores this interplay: cognitive impairment, including the neurocognitive disorders (formerly called the dementias). Cognitive impairment among older adults is a challenge for interdisciplinary diagnosis and treatment. Distinguishing among age‐related cognitive change, mild cognitive impairment (MCI), and Alzheimer’s disease or other major neurocognitive disorders can be difficult. (We discuss this important issue fully in Chapter 8.) In addition, differential diagnosis and prompt treatment requires ruling out a myriad of potentially reversible causes of confusional states: drug reactions, mental disorders, metabolic disorders, impaired vision and hearing, nutritional deficiencies, dehydration, brain tumors and traumas, and infections. This requires an interdisciplinary collaboration designed to assess complex patterns of comorbidity, in which distinctions between physical disorder and mental disorder become blurred.
Fourth, and finally, Cohen (1992) suggests that social and psychosocial resources can affect the course of physical and mental disorders. As we discuss in the stress and coping model (see Chapter 6), social support can buffer the negative effects of life stress and help people cope better with a myriad of problems. Even among those with a cognitive disorder, a positive social environment can enhance the person’s dignity and quality of life.
Individual Differences and Assessment of Risk
Thus far, we have sketched general patterns of mental health and mental disorder among older adults, as a context for working with Mr. Tucker. One question has been implicit in this discussion: How is Mr. Tucker like other older adults of his age? In this section, the emphasis shifts to another question: How is Mr. Tucker different from other individuals his age?
What do we know about Mr. Tucker that would differentiate him from other 81‐year‐olds? What are the categories of information we would use in sorting older adults? Socioeconomic status (SES) dramatically affects the experience of aging. Consider the relationships among age, having a chronic health problem, and SES (see Figure 1.3). Data from the Behavioral Risk Factors Surveillance System (CDC, 2010) showed that individuals in the lower SES categories have the highest rates of chronic conditions throughout adulthood.
Figure 1.3 Percentage of respondents reporting that they have a chronic health problem stratified by age and socioeconomic status (SES).
Source: Adapted from Centers for Disease Control’s Behavior Risk Factor Surveillance System (2007).
Moreover, by early mid‐life (ages 35‐44), those in the lower SES group already have chronic health problems at higher rates than those in the highest SES group at ages 55–64, 65–74, and 75+. Variability in risk among older adults is not limited to the physical or functional domains, however. There are similar patterns of variability in risk of mental disorders. Consider the risk for suicide. We resume our conversation with Mr. Tucker:
… “I never made much of my life. But I do know that it won’t be hunting season without Ed. Just can’t do it alone, and nobody in their right mind would want to hunt with an old fool like me.”
These words have a haunting finality to them. As you hear them, you begin to wonder about Mr. Tucker’s will to live and his plans for the future. Should you ask him about these elements, about his potential for self‐harm or suicide?
Psychiatric epidemiological data can be helpful in tracing patterns of suicide risk across the lifespan in the US (see Figure 1.4). Overall, a total of 42,773 people died by suicide in 2014. Suicide death rates climb from early adulthood and then peak in both the 45–54 year old group and the 85+ year old group. Aggregated across later‐life (65+), the threat of completed suicide is substantial, with older adults having a higher suicide death rate (16.6 per 100,000 people) than for the general population (13.4 per 100,00 people; Drapeau & McIntosh, 2015). Across the lifespan, men are much more likely to die by suicide than women, with 3.4 male deaths by suicide for each female death by suicide. White men are at especially elevated risk (24.1 per 100,000 people) with older White men at the absolute greatest risk of any group.
Figure 1.4 Suicide death rates per 100,000 people, ages 5 to 85+ for 2014 in the US.
Source: Adapted from Drapeau & McIntosh (for the American Association of Suicidology; 2015).
Armed with this knowledge of differential risk—particularly for white men over 80—you ask Mr. Tucker about his current plans and perspectives:
“It sounds like you’re feeling pretty blue. Have you ever thought about hurting yourself in any way?”
“I may be down, but I’m not crazy!”
Mr. Tucker quickly gives you a sense of his own perspective on his problems, allowing you to follow up with specific questions regarding intent. The conversation could have gone in a different direction:
“It sounds like you’re feeling pretty blue. Have you ever thought about hurting yourself in any way?”
“Every now and then I get that feeling.”
“I’m sorry to hear you are in so much pain. Have you thought about how you would do it?”
“Well, I’d use that shotgun that I keep loaded next to the door—just head out to the barn, clear out the cows, and pull the trigger…”
This conversation confirms your fears—he has motivation, a way to achieve that purpose, and seemingly little concern about the consequences.
These two resolutions to the inquiry highlight the theme of variability among and between older adults. This variability is a hallmark of aging: As we grow older, we become increasingly distinct from our age‐mates. This diversity among older adults (often called inter‐individual differences) is the result of the complex patterns of both biological and biographical functioning across the life span.
The biographical elements may play a key role in two different ways: the history of the disorder and the history of the individual. In the case of Mr. Tucker’s suicide potential, for example, we will want to know something about his previous experience with suicidal ideation: Has he been suicidal for many years and now grown older? Or, has he grown older and now become suicidal? These two divergent paths both arrive at suicidal risk in later life, but they offer very different suggestions for treatment attempts, the availability of social and emotional resources, and the likelihood of successful intervention.
In summary, we will want to know more about several key elements of Mr. Tucker’s history: his social and economic resources, his current and past physical health, his current and past mental health, and his functional abilities. Approaches to these issues will be presented in Part II of this book.
The Context of Clinicians and Clients: Now What Do We Do?
Thus far, we have had one conversation with Mr. Tucker and we have gathered information about his current functioning, his previous history, and his future ability to continue to cope on his own. What will we do next?
