Addressing Mental Health Needs of Older Adults
People 65 years of age and older are the fastest growing segment of the U.S. population. An increasing number of older adults are immigrants or members of ethnic or racial minority groups. More than 5 million older adults were below the poverty level or classified as "near poor" in 2001.
Most older adults enjoy good mental health. However, it is anticipated that the number of older adults with mental and behavioral health problems will almost quadruple, from 4 million in 1970 to 15 million in 2030. Mental health disorders, including anxiety and depression, adversely affect physical health and ability to function, especially in older adults. Some late-life problems that can result in depression and anxiety include coping with physical health problems, caring for a spouse with dementia or a physical disability, grieving the death of loved ones, and managing conflict with family members.
Addressing these problems and treating often overlooked mental health conditions results in decreased emotional suffering, improved physical health, lessened disability, and a better quality of life for older adults and their families. Increasing access to mental health services for older adults will reduce health care expenditures by lowering the frequency of primary care visits, medical procedures, and medication use.
Psychologists play a significant role in addressing the mental health needs and supporting the strengths of our growing population of older adults. Collectively, psychologists provide more than 50,000 hours of care each week to older adults, and 70% of practicing psychologists provide some services to older adults. Studies show that the majority of students in psychology doctoral training are interested in working with and expect to provide clinical services to older adults during their careers.
Psychologists provide services to older adults in a variety of settings, including health care facilities, community-based private or group practices, and places where older adults reside—in their homes, longterm-care and assisted-living facilities, and hospices. Psychologists work both independently and as members of interdisciplinary teams. As team members, psychologists collaborate with a variety of professionals, including medical and other mental health care services providers, to ensure comprehensive care.
What Is Psychology?
What Is Geropsychology?
The Growing Need for Psychological Services for Older Adults
The demand for mental health practitioners with expertise in older adult care will expand as the older population grows. Demand for mental health services is expected to rise as large cohorts of middle-aged individuals—who are more accepting of mental health services than the current generation of older people—move into old age.
Researchers estimate that almost two-thirds of older adults with a mental disorder do not receive needed services. This problem is particularly acute in rural and underserved groups, such as those living in poverty and some ethnic and racial groups.
Research suggests that a majority of older adults would want to be treated should they become depressed. When given a choice for the treatment of depression, older adults often prefer psychological services to antidepressant medication. Older adults report feeling comfortable receiving mental health services from qualified mental health professionals.
The Interface Between Physical and Mental Health Care
Studies indicate that 50-70% of all primary care medical visits are related to psychological factors such as anxiety, depression, and stress. In rural and underserved areas, it may be that primary care medical services are the only health care available.
Physical and mental health affect each other. For example, older adults with medical problems such as heart disease have higher rates of depression than those who are medically well. Conversely, untreated depression in an older person with heart disease negatively affects the outcome of the disease. Even mild depression lowers immunity and may compromise a 2 person's ability to fight infections and cancers.
Depression has a powerful negative impact on ability to function, resulting in high rates of disability. The World Health Organization projects that by the year 2020, depression will remain a leading cause of disability, second only to cardiovascular disease.
Recognition and treatment of mental health conditions in the medically ill may be especially difficult. As most older adults have one or more chronic medical conditions, psychologists' skills are particularly useful in diagnosis and treatment.
Integration and coordination of care by geropsychologists with primary care professionals have been shown to decrease the frequency of older adults' primary care visits and use of medication.
Policy Recommendations To Improve Mental Health Care for Older Americans
Enhance opportunities for professional training in the psychology of aging at the doctoral and postdoctoral levels of education to address the growing number of older adults in need of mental and behavioral health services.
Expand basic and applied behavioral research at the National Institute of Mental Health and the National Institute on Aging. Increase funding for research training in geropsychology and for the widespread dissemination of evidence-based psychological treatment for mental healthproblems of older adults.
Increase the early identification and treatment of older adults with mental health problems through outreach and the provision of services offered in places older adults frequent, such as primary care settings, congregate meal and senior centers, residential settings, libraries, and other community sites.
Support legislation to increase the availability of and access to effective mental health services for older adults. Barriers to treatment include financial costs; lack of parity between reimbursement of health vs. mental health services; poor recognition and diagnosis of mental health conditions among older adults; lack of programs focusing on older adult mental health issues; reluctance of primary care providers to refer to mental healthprofessionals; transportation; living in a rural or underserved area; and stigma.
Increase funding through Medicaid, the Older Americans Act, and the Community Mental Health Services Block Grant to expand the availability of mental health and related supportive services to older adults.
Increase coordination of mental and physical health care. Because of the often-complex interplay of physical and mental health problems in older adults, interdisciplinary care is needed to provide optimal care.
How Psychologists Address the Needs of Older Adults—Some Examples
Psychologists are at the forefront of research on questions related to health and aging. Why are most older adults successful in adapting to the stressors of late life, while others become suicidal? Why do most older adults remain mentally sharp, while others have memory problems? Research on the aging brain provides clues to the risks and protective factors for mental disorders across the life span.
Given the often-complex mental and physical health problems of older adults, health care providers and families often turn to psychologists because of their skills in psychological and neuropsychological assessment. Psychologists are also the leading scientists responsible for the development of diagnostic tools. Psychologists have the necessary expertise to assess and differentiate between disorders such as dementia, depression, anxiety, delirium, adjustment reactions, side effects from medications, or combinations of these problems. The legal profession looks to psychologists to help determine whether older adults have the capacity to manage their own affairs.
As with younger adults, a variety of mental health disorders, such as anxiety and depression, affect older adults. Stressors common in late life significantly affect the health and independence of older adults. Life stressors include adapting to and coping with late-life transitions, grief, poverty, multiple medical conditions, functional limitations, cognitive changes, chronic pain, and care for an infirm family member.
Psychologists use psychological interventions, including various psychotherapies, to help older adults deal with mental health disorders and late-life stressors. The most common psychological interventions include cognitive–behavioral, interpersonal, and psychodynamic psychotherapy; behavior modification and disease management strategies; cognitive training techniques; and environmental modification. Alone or in combination with psychiatric medications, psychological interventions have been shown to be effective in the treatment of many mental health disorders. The availability of nonpharmacological treatments for mental health problems is especially important for older adults. This is because they are often on multiple medications for physical health problems, are more prone to certain adverse side effects of psychiatric medications than younger individuals, and, as noted, often prefer psychotherapy to psychiatric medications.
Psychologists conduct research on and provide treament for a wide range of mental health disorders and life problems that affect older adults including the following.
Adjustment to the stressors of late life. Psychologists work with older patients to deal with the many life stressors that accompany aging, such as decline in health, loss of loved ones, and relocation to a new living situation.
Anxiety disorders. Psychologists use psychotherapy and supportive counseling to treat anxiety disorders in older adults, the frequency of which is comparable to that of depression in older people. Anxiety-related disorders include generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and obsessive–compulsive disorder.
Capacity assessment. Families, health care providers, attorneys, and judges concerned about an older person's capacity to make medical or legal decisions call upon psychologists. Psychologists have been leaders in the development of the instruments that assess specific capacities in older adults.
Caregiving. Family caregivers provide care to most of the 10 million older adults in the United States who have a disabling condition. Although the role of caregiving can be rewarding, it can also be quite stressful and taxing. Caregivers may suffer from depression, anxiety, substance abuse, anger, and stress-related health problems, including cardiovascular disease. Psychologists help family members to better deal with the practical and emotional demands of caring for a physically or cognitively impaired older relative.
Dementia. Psychologists help individuals who are in early stages of dementia build coping strategies and reduce distress through psychotherapy and psychoeducational support groups. Memory training strategies help to optimize remaining cognitive abilities. Psychologists also teach behavioral and environmental strategies to caregivers of those with dementia to deal with common behaviors such as aggression and wandering. Unlike sedating medications, these strategies do not lead to additional confusion or impairment of mental functioning. In addition, as individuals with dementia often also suffer from depression, paranoia, and anxiety, the psychologists' skills in differential diagnosis and treatment are helpful in these complex cases.
Depression. Depression in older adults is a very treatable disorder. However, symptoms of depression in older adults are often overlooked because they are inaccurately assumed to be a normal part of aging or may coincide with medical illnesses or life events that commonly occur as people age. Psychologists successfully identify and treat both major depressive disorder and subclinical forms of depression with psychotherapy.
End-of-life care. Psychologists assist older adults and their families with advanced care planning. They counsel terminally ill patients and their families on how to manage feelings, decrease distress, and manage pain, and after the death, grief. As depression and anxiety are often associated with a terminal diagnosis and the progression of a disease, psychologists assess and treat these mental health conditions to minimize suffering and distress. Psychologists also train physicians to recognize and ameliorate patient and caregiver psychological distress.
Health promotion. As experts in human behavior, psychologists have been at the forefront in developing effective health promotion programs and strategies to enhance healthy behaviors. Two examples of health promotion efforts that have proven beneficial for older adults include memory-training programs that enhance memory performance and physical activity programs that elevate mood, relieve symptoms of depression, and contribute to the effective management of hypertension and diabetes.
Incontinence. Psychologists use behavioral training methods, such as biofeedback, bladder training, goal setting, and self-monitoring, to reduce incontinence. These treatments have proven to be more effective than drug therapy. Incontinence has significant implications for the independence of older adults. It is the second most common reason why families admit an elder relative to a nursing home, which in itself is associated with depression in older adults.
Insomnia. Insomnia is prevalent among older adults, especially medically ill elders. Older adults are especially vulnerable to the adverse effects of sleep medications, including memory impairment and impaired daytime performance. Psychologists have developed effective nonpharmacologic treatments for insomnia, including cognitive–behavioral techniques, sleep restriction and stimulus control, and sleep hygiene instruction.
Long-term care. There is a very high prevalence of mental health disorders in long-term care institutions, such as nursing homes. Psychologists' presence in these settings has greatly increased in the past decade. Psychologists work with facility staff to more effectively manage resident behavioral problems, such as aggression and wandering, and to improve quality of life for both staff and residents. Psychologists work with individuals and with groups of residents to help them better adjust to life in long-term care, medical problems, depression, anxiety, and the loss of cognitive abilities.
Management of chronic diseases. Psychologists help older adults manage multiple chronic medical conditions that often accompany aging, such as heart disease, stroke, and arthritis. A major goal of such management is to prevent excess disability and hospitalization through treatment adherence and behavioral interventions, including physical activity, biofeedback, nutrition, and stress reduction techniques.
Substance abuse. Alcohol abuse is a significant problem for some older adults and is one the eight leading causes of death among older Americans. Psychologists can help older adults boost their motivation to stop drinking, identify circumstances that trigger drinking, and learn new methods to cope with high-risk drinking situations. Some older adults have problems with addiction to prescription medication for anxiety and need help in reducing or stopping medication. In addition, as the baby boomer cohort enters old age, the prevalence of both alcohol and illicit drug use will likely increase.
Suicide. Older adults, particularly White men, have the highest rates of suicide in the United States. Depression is suicide's foremost risk factor. Psychologists are skilled at identifying depression and assessing for suicide risk. Those at risk for suicide are often not identified by primary health care providers. It has been reported that two-fifths of older adults who commit suicide visited a physician within the past week and three-quarters within the past month. Primary care providers often overlook the potential link between physical symptoms and mental health problems.
For More Information About Psychology and Aging
The American Psychological Association (APA) is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists.
The APA Office on Aging in the APA Public Interest Directorate serves as the coordination point for the association's activities pertaining to aging. It is an information and referral resource that strives to bring psychological knowledge to bear on discussions regarding matters that affect older adults and their families. The office can help link you with the most current research findings, effective psychological interventions, and the premier researchers and practitioners in the health and aging field. For more information, contact:
APA Office on Aging
The APA Committee on Aging (CONA) is the committee within the APA governance structure dedicated to aging issues. Its six expert members are selected for 3-year terms. CONA works to advance psychology as a science and profession and as a means of promoting the health and human welfare of older adults through expanded scientific understanding of adult development and aging and the delivery of appropriate psychological services to older persons.
APA Division 20 (Adult Development & Aging) is composed of APA members concerned with the study of psychological development and change throughout the adult years.
APA Division 12-II (Clinical Geropsychology) is composed of APA members devoted to research, training, and providing psychological services for older adults.
Many of the mental and behavioral health problems inaccurately attributed to the natural aging process are preventable or treatable.
About two-thirds of older adults with a mental disorder do not receive needed services. The need and demand for these services are expected to increase because of the growing older population and the increased acceptance and utilization of mental health services by aging baby boomers.
Barriers to mental health services that older adults face include financial costs of service, poor diagnosis and referral to mental health professionals of older adults seen in primary care settings, shortage of mental health professionals trained to work with older adults, and lack of available specialized mental health services and programs.
Older adults often have complex, interacting mental and physical health problems that make the recognition and treatment of mental health disorders especially difficult.
Psychologists are highly qualified health care providers skilled in the assessment and treatment of the problems of older adults, their families, and caregivers.
Psychological research has contributed significantly to the understanding and treatment of the major health concerns of our time: heart disease, cancer, AIDS, mental disorders, dementia, diabetes, chronic pain, chronic respiratory ailments, and arthritis, among others.