Swedish researchers found much higher rates of
suicidal ideation after interviewing adults aged 85 years
and older. They found a 1-month prevalence of any
suicidal feelings in 9.6 percent of men and 18.7 percent
of women (Skoog et al., 1996). Suicidal feelings were
strongly associated with depression. For example, 6.2
percent of the participants who did not meet criteria for
depression or anxiety reported suicidal thoughts, while
almost 50 percent of those meeting criteria for
depression reported such thoughts. The higher
prevalence of suicidal feelings in this study, compared
with that cited earlier, is likely due to the older age of
subjects and to methodological differences.

Studies of older persons who have committed
suicide have revealed that older adults had seen their
physician within a short interval of completing suicide,
yet few were receiving mental health treatment. Caine
and coworkers studied the records of 97 adults aged 50
years and older who completed suicide (Caine et al.,
1996). Of this group, 51 had seen their primary care
physician within 1 month of the suicide. Forty-five had
psychiatric symptoms. Yet in only 29 of the 45
individuals were symptoms recognized, in only 19 was
treatment offered, and in only 2 of these 19 cases was
the treatment rendered considered adequate. Treatment
was deemed inadequate if an incorrect medicine (such
as a benzodiazepine for severe major depression) or
inadequate dose was prescribed. This line of research
highlights important
prevention.

opportunities for suicide

Depression also can lead to increased mortality
from other diseases, such as heart disease and possibly
cancer. How depression exerts these effects is not yet
understood. In nursing home patients, major depression
increases the likelihood of mortality by 59 percent,
independent of physical health measures (Rovner,
1993). In the case of myocardial infarction, depression
elevates mortality risk fivefold (Frasure-Smith et al.,
1993, 1995). Depression also has been linked to the
onset of cancer, but results have been inconsistent. Yet
a new epidemiological study, considered the most
compelling to date, finds that chronic depression
(lasting an average of about 4 years) raises the risk of
cancer by 88 percent in older people (Penninx et al.,

351

Older Adults and Mental Health

1998). Thus, increased understanding of depression in
older people may be, literally, a matter of life and

death.

Cost

The high prevalence of depressive syndromes and
symptoms in older adults exacts a large economic toll.
Depression as a whole for all age groups is one of the
most costly disorders in the United States (Hirschfeld
et al., 1997). The direct and indirect costs of depression
have been estimated at $43 billion each year, not
including pain and suffering and diminished quality of
life (Finkelstein et al., 1996). Late-life depression is
particularly costly because of the excess disability that
it causes and its deleterious interaction with physical
health. Older primary care patients with depression
visit the doctor and emergency room more often, use
more medication, incur higher outpatient charges. and
stay longer at the hospital (Callahan et al., 1994,
Cooper-Patrick et al., 1994: Callahan & Wolinsky,
1995; Unutzer et al., 1997b).

Etiology of Late-Onset Depression

Despite major advances, the etiology of depression
occurring at any age is not fully understood, although
biological and psychosocial factors clearly play an
important and interactive role.

With respect to late-onset depression, several risk
factors have been identified. Persistent insomnia,
occurring in 5 to 10 percent of older adults, is a known
risk factor for the subsequent onset of new cases of
major depression both in middle-aged and older
persons (Ford & Kamerow, 1989). Grief following the
death of a loved one also is an important risk factor for
both major and minor depression. At least 10 to 20
percent of widows and widowers develop clinically
significant depression during the first year of
bereavement. Without treatment, such depressions tend
to persist, becoming chronic and leading to further
disability and impairments in general health (Zisook &
Shuchter, 1993). A final pathway to late-onset
depression, suggested by computed tomography and
magnetic resonance imaging studies, may involve
structural, neuroanatomic factors. Enlarged lateral
Mental Health: A Report of the Surgeon General

ventricles, cortical atrophy, increased white matter
hyperintensities, decreased caudate size, and vascular
lesions in the caudate nucleus appear to be especially
prominent in late-onset depression associated with
vascular risk factors (Ohayon et al., 1996; Baldwin &
Tomenson, 1995). These findings have generated the
vascular hypothesis of late-onset depression; namely,
that even in the absence of a clear stroke, disorders that
cause vascular damage, such as hypertension, coronary
artery disease, and diabetes mellitus, may induce
cerebral pathology that constitutes a vulnerability for
depression (Alexopoulos et al., 1997, Steffens &
Krishnan, 1998).

Treatment of Depression in Older Adults
A broad array of effective treatments,

pharmacological and psychosocial,

both
exists for
depression. Despite the pervasiveness of depression
and the existence of effective treatments, a substantial
fraction of patients receive either no treatment or
inadequate treatment, as described earlier. Some of the
barriers relate to underdiagnosis, while others relate to
treatment where there are patient, provider, and clinical

barriers (for more details, see Unutzer et al., 1996).

Pharmacological Treatment
There is consistent evidence that older patients, even

the very old, respond to antidepressant medication
(Reynolds & Kupfer, 1999). About 60 to 80 percent of
older patients respond to treatment, while the placebo
response rate is about 30 to 40 percent (Schneider,
1996). These rates are comparable to those in other
adults (see Chapter 4). Treatment response is typically
defined by a significant reduction—usually 50 percent
or greater—in symptom severity. Yet because patients
75 years old and older typically have higher prevalence
of medical comorbidity, both they and their physicians
are often reluctant to add another medication to an
already complex regimen in a frail individual.
However, newer antidepressants are less frequently
associated with factors contraindicating their use.
Moreover, because the very old are also at high risk for
adverse medical outcomes of depression and for
suicide, treatment may be favored. Despite the

352

availability of effective treatments, a minority of
patients properly diagnosed with depression receive
adequate dosage and duration of pharmacotherapy, as
noted earlier.

In general, treatment of
depression in older people is similar to that in other
adults, but the selection of medications is more
complex because of side effects and interactions with
other medications for concomitant somatic disorders.

pharmacological

Treatment of minor depression is generally the same as
treatment for major depression, but there is not a large
body of evidence to support this practice. Studies are
under way to identify effective _pharmacological
treatments for minor depression (Lebowitz et al., 1997).

The following paragraphs describe the major
classes of medications for treatment of depression in
older adults. They focus on side effects and other
concerns that distinguish the treatment of depression in
older adults from that in younger ones.

Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) have been widely
used to treat depressed patients of all ages.
Alexopoulos and Salzman (1998) reviewed studies of
TCAs in older depressed patients and concluded that
these compounds are similar in efficacy across the age
the effect profiles differ
considerably. Widespread use of the TCAs in older
adults is limited by adverse reactions. While
anticholinergic effects such as dry mouth, urinary

spectrum, but side

retention, and constipation can be annoying in younger
adults, they can lead to severe problems in older adults.
For example, constipation can lead to impaction, and
dry mouth can prevent the wearing of dentures. The
anticholinergic effects of the TCAs may also cause
tachycardia or arrhythmias and can further compromise
preexisting cardiac disease (Roose et al., 1987;
Glassman et al., 1993). Central anticholinergic effects
may result in acute confusional states or memory
problems in the depressed older adult (Branconnier et
al., 1982). Orthostatic hypotension, which may lead to
falls and hip fractures, is also a concern when the TCAs
are administered. Nevertheless, TCAs are still frequent-
ly used in older adults.
selective Serotonin Reuptake Inhibitors and Other
Newer Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) such as
fluoxetine, paroxetine, and sertraline, whose use is
increasing across age groups, may be especially useful
in the treatment of late-life depression, because these
agents are reported to have fewer anticholinergic and
cardiovascular side effects than the TCAs. The more
effects with SSRIs include
sexual dysfunction and gastrointestinal effects such as
nausea, vomiting, and loose stools. Treatment with the
SSRIs may also produce insomnia, anxiety,

commonly observed side

and
restlessness. The few studies that have examined the
efficacy of these compounds in older adults have
shown efficacy similar to the TCAs and fewer side
effects (see Small & Salzman, 1998, for a review).
While the relative efficacy of SSRIs and TCAs is still
debated, SSRIs are easier to prescribe because of
simpler dosing patterns and more manageable side
effects.

One concern when prescribing the SSRIs in older
adults is the potential for drug-drug interactions. This
is of clinical importance since older adults commonly
receive a large number of medications. The SSRIs vary
in their inhibition of the cytochrome p450 family of
isoenzymes. Knowledge of these patterns of inhibition
in the SSRIs and other medications commonly used in
older adults (such as other psychoactive compounds,
calcium channel blockers, or warfarin) can help to
avoid or minimize interactions. Other newer non-SSRI
antidepressants (venlafaxine, bupropion, trazodone, and
nefazodone) are often suggested for treating later life
depression because their side effects are better tolerated
by older adults.

Some compounds that are useful in other
individuals may be less useful for treatment of older
patients. For example, despite evidence of the efficacy
of monamine oxidase inhibitors (see Alexopoulos &
Salzman. 1998, for a review), clinical use is often
restricted to patients who are refractory to other
antidepressant drugs. This is due to potentially
life-threatening pharmacodynamic interactions with
sympathomimetic drugs or tyramine-containing foods
and beverages. The sympathomimetic amines (e.g.,

353

Older Adults and Mental Health

phenylpropanolamine and pseudoephedrine) may be
present in over-the-counter decongestant products that
older patients are prone to self-administer. An
additional concern is the risk of orthostatic
hypotension, which occurs even at therapeutic doses
(Alexopoulos & Salzman, 1998). In addition,
bupropion has been shown in older patients to be as
effective as TCAs (Branconnier et al., 1983; Kane et
al., 1983). Although generally well tolerated, its use
requires added caution because of an increased risk of
seizures and thus should be avoided in patients with
seizure disorder or focal central nervous system
disease. Its advantages include a relatively low
incidence of cardiovascular complications and a lack of
confusion.

Multimodal Therapy

Combining pharmacotherapy with psychosocial
interventions also appears to be effective in older
depressed patients. A high response rate of about 80
percent was found for acute and continuation treatment
with combined nortriptyline and interpersonal
psychotherapy. The response rate was similar between
so-called “young old” patients (primarily in their 60s
and early 70s) and patients in their 30s and 40s
(Reynolds et al., 1996). Yet older patients showed a
somewhat longer time to remission than did other
patients (about 2 weeks longer) and twice the rate of
relapse during continuation treatment (about 15 percent
versus 7 percent). However, because the trial was not
controlled, it is not known whether multimodal
effective than either
pharmacological or psychosocial treatment alone.

treatment was more
Treatment resistance—defined by the lack of recovery
in spite of combined treatment with nortriptyline and
interpersonal psychotherapy—was seen in about 18
percent of older patients with recurrent major
depression (nonpsychotic unipolar depression) (Little
et al. 1998). Nortriptyline and
psychotherapy (IPT) have been shown to be effective
late-life depression. After

interpersonal

maintenance treatments for
3 years of comparing various treatments, the percentage
of older adults who did not experience recurrence were

57 percent of older adults receiving nortriptyline, 36
Mental Health: A Report of the Surgeon General

percent receiving IPT, and 80 percent of those
receiving nortriptyline plus IPT. Those receiving a
placebo and routine clinical visits had a 90 percent
recurrence rate (Reynolds et al., 1999).

Course of Treatment

Although 60 to 80 percent of older patients with
moderate to severe unipolar depression’ can be
expected to respond well to antidepressant treatment
(especially combined treatment with medication and
psychotherapy), the clinical response to antidepressant
treatment in later life follows a variable course, with a
median time to remission of 12 weeks (J. L. Cummings
& D.J. Kupfer, personal communication, 1999). Thus,
treatment response takes 1 month or more longer than
that for other adults, for whom treatment response takes
an average of 6 to 8 weeks (see Chapter 4). In addition
to highly variable trajectories to recovery, reliable
prediction of response status (recovery/nonrecovery) is
generally not possible in older adults before 4 to 5
weeks of treatment. The delayed onset of
antidepressant activity in older adults leads to unique
problems. Suffering and disability are prolonged, which
often reduces compliance and may increase risk for
suicide. The development of strategies to accelerate
treatment response and to improve the early
identification of nonresponders would be an important
advance (Reynolds & Kupfer, 1999).

Data from naturalistic studies have identified
several predictors of relapse and recurrence in late-life
depression, including a history of frequent episodes,
first episode after age 60, concurrent somatic illness,
especially a history of myocardial infarction or vascular
disease. high pretreatment severity of depression and
anxiety, and cognitive impairment, especially frontal
lobe dysfunction. These factors appear to interact with
low treatment intensity—that is, at dosage and duration
below recommended levels—in determining more
severe courses of illness. Despite the evidence that high
treatment intensity is effective in preventing relapse
and recurrence (Reynolds et al., 1995), naturalistic

 

Unipolar depression refers to the depression in patients with
major depressive disorders but not to the depression in patients
with bipolar disorders.

354

studies have shown that intensity of treatment
prescribed by psychiatrists begins to decline within 16
weeks of entry and approximately 10 weeks prior to
1996). Residual
symptoms of excessive anxiety and worrying predict
early recurrence after tapering continuation treatment
in older depressed patients (Meyers, 1996).

Although progress has been made in identifying
effective pharmacological and combined treatments for
late-life depression, there is a need for more outcome
studies with newer antidepressants. In addition, studies
examining effectiveness in real-world settings—rather
than in clinical trials conducted in academic clinical
sites—are particularly crucial in the older population
because of medical comorbidity and provision of care
in primary, rather than specialty, care.

recovery (Alexopoulos et al.,

Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is regarded as an

effective intervention for some forms of treatment-
resistant depression across the life cycle (NIH & NIMH
Consensus Conference, 1985; Depression Guideline
Panel, 1993). It may offer a particularly attractive
benefit:risk ratio in older persons with depression (NIH
Consensus Development Panel on Depression in Late
Life, 1992; Sackeim, 1994). Chapter 4 reviews research
on ECT and considers risk-benefit issues and
controversy surrounding them. As described there, ECT
entails the electrical induction of seizures in the brain,
administered during a series of 6 to 12 treatment
sessions on an inpatient or outpatient basis. Practice
guidelines recommend that ECT should be reserved for
severe cases of depression, particularly with active
suicidal risk or psychosis; patients unresponsive to
medications; and those who cannot tolerate medications
(NIH & NIMH Consensus Conference, 1985; Depres-
sion Guideline Panel, 1993). For those patients, the
response rate to ECT is on the order of 50 to 70
percent, and there is no evidence that ECT is any less
effective in older individuals than younger ones
(Sackeim, 1994; Weiner & Krystal, 1994). ECT is
advantageous for older people with depression because
of the problems with
medications, including sensitivity to anticholinergic

special they encounter
toxicity, cardiac conduction slowing, and hypotension
(see above). Although the newer antidepressants offer
4 more favorable side-effect profile than do the older
tricyclics, their efficacy in melancholic depression, for
which ECT is particularly helpful (Rudorfer et al.,
1997), is not yet firmly established. Moreover, as noted
earlier, older adults respond more slowly than younger
ones to antidepressant medications, rendering the faster
onset of action of ECT another advantage in the older
patient (Markowitz et al., 1987). Immobility and
reduced food and fluid intake in the older person with
depression may pose a greater imminent physical health
risk than would typically be the case in a younger
patient, again strengthening the case for considering
ECT early in the treatment hierarchy (Sackeim, 1994).

Although the clinical ,effectiveness of ECT is
documented and acknowledged, the treatment often is
associated with troubling side effects, principally a
brief period of confusion following administration and
a temporary period of memory disruption (Rudorfer et
al., 1997). As described in Chapter 4, there may also be
longer term memory losses for the time period
surrounding the use of ECT. Although the exception
rather than the rule; persistent memory loss following
ECT is reported. Its actual incidence is unknown. There
are no absolute medical contraindications to ECT.
However, a recent history of myocardial infarct,
irregular cardiac rhythm, or other heart conditions
suggests the need for caution due to the risks of general
anesthesia and the brief rise in heart rate, blood
pressure, and load on the heart that accompany ECT
administration. On the other hand, the safety of ECT is
enhanced by the time-limited nature of treatment
sessions, which enables this intervention to be
administered under controlled conditions, for example,
with a cardiologist or other specialist in attendance.
Following completion of a course of ECT, maintenance
treatment. typically with antidepressant or mood-
stabilizing medication or less frequent maintenance
ECT, in most cases is required to prevent relapse
(Rudorfer et al., 1997).

355

Older Adults and Mental Health

Psychosocial Treatment of Depression
Most research to date on psychosocial treatment of

mental disorders has concentrated on depression. These
studies suggest that several forms of psychotherapy are
effective for the treatment of late-life depression,
including cognitive-behavioral therapy, interpersonal
psychotherapy, problem-solving therapy, brief psycho-
dynamic psychotherapy, and reminiscence therapy, an
intervention developed specifically for older adults on
the premise that reflection upon positive and negative
past life experiences enables the individual to
overcome feelings of depression and despair (Butler.
1974; Butler et al., 1991). Group and individual
formats have been used successfully.

A meta-analysis of 17 studies of cognitive,
behavioral, brief psychodynamic, interpersonal, remini-
scence, and eclectic therapies for late-life depression
found treatment to be more effective than no treatment
or placebo (Scogin & McElreath, 1994). The following
paragraphs spotlight some of the key studies
incorporated into this meta-analysis and provide
evidence from newer studies.

Cognitive-behavioral therapy is designed to modify
thought patterns, improve skills, and alter the emotional
states that contribute to the onset, or perpetuation, of
mental disorders. In a 2-year followup study of
cognitive-behavioral therapy, 70 percent of all patients
studied no longer met criteria for major depression and
maintained treatment gains (Gallagher-Thompson et al..
1990). In another trial, group cognitive therapy was
found to be effective. Older patients with major
depression partially randomized to receive group
cognitive therapy with alprazolam (a benzodiazepine)
or group cognitive therapy with placebo had more
improvement in depressed mood and sleep efficiency
than patients who received alprazolam alone or placebo
alone (Beutler et al., 1987). Cognitive-behavioral
therapy also has been demonstrated to be effective in
other late-life disorders. including anxiety disorders
(Stanley et al., 1996, Beck & Stanley, 1997).
Cognitive-behavioral therapy’s effectiveness for mood
symptoms in Alzheimer’s disease is discussed in the
section on psychosocial treatments of Alzheimer’s
disease.
Mental Health: A Report of the Surgeon General

Problem-solving therapy postulates that
deficiencies in social problem-solving skills enhance
the risk for depression and other psychiatric symptoms.
Through improving problem-solving skills, older
patients are given the tools to enable them to cope with
stressors and thereby experience fewer symptoms of
psychopathology (Hawton & Kirk, 1989). Problem-
solving therapy has been found effective in the
treatment of depression of older patients. For example,
problem-solving therapy was found to significantly
reduce symptoms of major depression, leading to the
greatest improvement in a randomized controlled study
comparing problem-solving therapy, reminiscence
therapy, and placement on a waiting list for treatment
(Arean et al., 1993). In a randomized study of
depressed younger primary care patients, six sessions
of problem-solving therapy were as effective as
amitriptyline, with about 50 to 60 percent of patients in
each group recovering (Mynors-Wallis et al., 1995).
Interpersonal psychotherapy was initially designed
as a time-limited treatment for midlife depression. It
focuses on grief, role disputes, role transitions, and
interpersonal deficits (Klerman et al., 1984). This form
of treatment may be especially meaningful for older
patients given the multiple losses, role changes, ‘social
isolation, and helplessness associated with late-life
depression. Controlled trials suggest that interpersonal
psychotherapy alone, or in combination with pharmaco-
therapy, is effective in all phases of treatment for late-
life major depression. Interpersonal psychotherapy was
as effective as the antidepressant nortriptyline in
depressed older outpatients, and both were superior to
placebo (Sloane et al., 1985; Reynolds et al., 1992;
Schneider, 1995). In an open trial, a treatment protocol
combining interpersonal psychotherapy with
nortriptyline and psychoeducational support groups led
to minimal attrition and high rates
(approximately 80 percent) in older patients with
recurrent major depression (Reynolds et al., 1992,
1994). Finally, interpersonal psychotherapy also is
effective in the treatment of depression following
bereavement (Pasternak et al., 1997).
_ Brief psychodynamic therapy, typically of 3 to 4
months’ duration, also is successful in older depressed

remission

356

patients. Brief psychodynamic therapy is distinguished
from traditional psychodynamic therapy primarily by
duration of treatment. The goals of brief psycho-
dynamic therapy vary according to patients’ medical
health and function. In disabled older people, the
purpose of psychodynamic psychotherapy is to
facilitate mourning of lost capacities, promote
acceptance of physical limitations, address fears of
dependency, and promote resolution of interpersonal
difficulties with family members (Lazarus & Sadavoy,
1996). In older patients who are not disabled,
psychodynamic psychotherapy deals with the resolution
of interpersonal conflicts, adaptation to loss and stress,
and the reconciliation of personal accomplishments and
disappointments (Pollock, 1987). Brief psychodynamic
therapy has been found to be as effective as cognitive-
behavioral therapy in reducing symptoms of late-life
major depression. An early study found brief
psychodynamic therapy to yield higher relapse and
recurrence rates than did cognitive and behavioral
therapy (Gallagher & Thompson, 1982). However, with
a greater number of patients, brief psychodynamic
therapy was determined to be as effective as cognitive
and behavioral therapy (and superior to being on a
waiting list) in preventing recurrences of major
depression up to 2 years

(Gallagher-Thompson et al., 1990).

after treatment

Alzheimer’s Disease

Alzheimer’s disease, a disorder of pivotal importance
to older adults, strikes 8 to 15 percent of people over
the age of 65 (Ritchie & Kildea, 1995). Alzheimer’s
disease is one of the most feared mental disorders
because of its gradual, yet relentless, attack on memory.
Memory loss, however, is not the only impairment.
Symptoms extend to other cognitive deficits in
object and executive

language, recognition,

functioning.2 Behavioral symptoms—such
psychosis, agitation, depression, and wandering—are
common and impose tremendous strain on caregivers.

Diagnosis is challenging because of the lack of

as

 

3 Executive functioning refers to the ability to plan, organize,
sequence, and abstract.
biological markers, insidious onset, and need to
exclude other causes of dementia.

This section covers assessment and diagnosis,
behavioral symptoms, course, prevalence and
incidence, cost, etiology, and treatment. It features
Alzheimer’s disease because it is the most prevalent
form of dementia. However, many of the issues raised
also pertain to other forms of dementia, such as multi-
dementia of Parkinson’s disease,
dementia of Huntington’s disease, dementia of Pick’s

disease, frontal lobe dementia, and others.

infarct dementia,

Assessment and Diagnosis of Alzheimer’s
Disease

Mild Cognitive Impairment
Declines in cognitive functioning have been identified
both as part of the normal process of aging and as an
indicator of Alzheimer’s disease. DSM-IV first
designated this as “age-related cognitive decline” and,
more recently, as “mild cognitive impairment” (MCT).
MCI characterizes those individuals who have a
memory problem but do not meet the generally
accepted criteria for Alzheimer’s disease such as those
issued by the National Institute of Neurological and
Communicative Disorders and Stroke-Alzheimer’ s
Disease and Related Disorders Association or DSM-IV.
MCI is important because it is known that a certain
percentage of patients will convert to Alzheimer’s
disease over a period of time (probably in the range of
15 to 20 percent per year). Thus, if such individuals
could be identified reliably, treatments could be given
that would delay or prevent the progression to
diagnosed Alzheimer’s disease. This is the rationale for
the Alzheimer’s Disease Cooperative Study trial of
vitamin E or donepezil for MCI, which began in 1999,
and it is also the basis for the use of neuroimaging in
early diagnosis. The evaluation of MCI spans the
boundary between normal aging and Alzheimer’s
disease, and this topic is being evaluated in a number of
research groups.

The diagnosis of Alzheimer’s disease depends on
the identification of the characteristic clinical features
and on the exclusion of other common causes of

357

Older Adults and Mental Health

dementia. There are currently no biological markers for
Alzheimer’s disease except for pathological
verification by biopsy or at autopsy (or through rare
autosomal dominant mutations). With the reliance on
clinical criteria and the need for exclusion of other
causes of dementia, the current approach to
Alzheimer’s diagnosis is time- and
labor-intensive, costly, and largely dependent on the
expertise of the examiner. Although genetic risk
factors, such as Apo-E status (see etiology section),
give some indication of the relative risk for
Alzheimer’s disease, they are as yet rarely useful on an
individual basis.

The diagnosis of Alzheimer’s disease not only
requires the presence of memory impairment but also
another cognitive deficit, such as language disturbance
or disturbance in executive functioning. The diagnosis
also calls for impairments in social and occupational
functioning that represent a significant functional
decline (DSM-IV). The other causes of dementia that
must be ruled out include cerebrovascular disease,
Parkinson’s disease, Huntington’s disease, subdural
hematoma, normal-pressure hydrocephalus, brain
tumor, systemic conditions (€.g-, hypothyroidism,
vitamin B,,

disease

or folic acid deficiency, niacin deficiency,
hypercalcemia, neurosyphilis, HIV infection), and
substance-induced conditions.

Some diagnostic schemes distinguish between
possible, probable, and definite Alzheimer’s disease
(McKhann et al., 1984). With these criteria, probable
Alzheimer’s disease is confirmed to be Alzheimer’s
disease at autopsy with 85 to 90 percent accuracy
(Galasko etal., 1994). Definite Alzheimer’s disease can
only be diagnosed pathologically through biopsy or at
autopsy. The pathological hallmarks of Alzheimer’s
disease are neurofibrillary tangles (intracellular
ageregates of a cytoskeletal protein called tau found in
degenerating or dead brain cells) and neuritic plaques
(extracellular deposits largely made up of a protein
called amyloid B-peptide) (Cummings, 1998b). (See
Figure 5-2.)

The diagnosis of dementia can be complicated by
the possibility of other disorders that coexist with, or
share features of, Alzheimer’s disease. For example,
Mental Health: A Report of the Surgeon General

____— PLAQUES

f

 

Figure 5-2. Neuritic plaques and many neurofibrillary tangles
in the hippocampus of an Alzheimer’s disease patient. (Photo
courtesy of Peter Davies, Ph.D., Department of Pathology,
Albert Einstein College of Medicine.)

delirium is a common condition in older patients and
can be confused with dementia in its acute stages.
Other types of dementia, such as vascular dementia,
share cognitive and behavioral symptoms with
Alzheimer’s disease, and thus may be difficult to
distinguish from Alzheimer’s disease. The cognitive
symptoms of early Alzheimer’s disease and those
associated with normal age-related decline also may be
similar. Finally, cognitive deficits are prominent in
both late-life depression and schizophrenia. While the
severity of deficits is less in these disorders than that in
later stages of dementia, distinctions may be difficult if
the dementia is early in its course.

A further challenge in the identification of
Alzheimer’s disease is the widespread societal view of
“senility” as a natural developmental stage. Early
symptoms of cognitive decline may be excused away or
ignored by family members and the patient, making
early detection and treatment difficult. The clinical
diagnosis of Alzheimer’s disease relies on an accurate
history of the patient’s symptoms and rate of decline.
Such information is often impossible to obtain from the
patient due to the prominence of memory dysfunction.
Family members or other informants are usually
helpful, but their ability to provide useful information
sometimes is hampered by denial or lack of knowledge
about signs and symptoms of the disorder.

358

With diagnosis so challenging, Alzheimer’s disease
and other dementias are currently underrecognized,
especially in primary care settings, where most older
patients seek care. In a study in the United Kingdom,
O’Connor and colleagues found that general
practitioners recognized only 58 percent of patients
identified by research psychiatrists using a structured
diagnostic interview (O’Connoretal., 1988). Similarly,
in a study conducted in the United States, Callahan and
colleagues found that only 3.2 percent of patients with
mild cognitive impairment were recognized by general
practitioners as having intellectual compromise, and
only 23.5 percent of those with moderate to severe
dementia were identified as having a dementia
syndrome (Callahan et al., 1995). The reasons for
primary care provider difficulty with diagnosis are
speculated to include lack of knowledge or skills,
misdiagnosis of depression as dementia, lack of time,
and lack of adequate referrals to specialty mental health
care.

The urgency of addressing obstacles to recognition
and accurate diagnosis is underscored by promising
studies that point to the pronounced clinical advantages
of early detection. Therapies that slow the progression
of Alzheimer’s disease or improve existing symptoms
are likely to be most effective if given early in the
clinical course. Recognition of early Alzheimer’s
disease, in addition to facilitating pharmacotherapy, has
a variety of other benefits that improve the plight of
patients and their families. Direct benefits to patients
include improved diagnosis of other potentially
reversible causes of dementia, such as hypothyroidism,
and identification of sources of Alzheimer’s disease’s
excess disability such as depression and anxiety that
can be targeted with nonpharmacological interventions.
Family members benefit from early detection by having
more time to adjust and plan for the future and by
having the opportunity for greater patient input into
decisions regarding advanced directives while the
patient is still at a mild stage of the illness (Cummings
& Jeste, 1999).

Diagnosis of Alzheimer’s disease would be greatly
improved by the discovery of a biological marker that
correlates strongly with neuropathological signs of
Alzheimer’s disease, reflects the severity of
pathological changes in Alzheimer’s disease, and
precedes the appearance of clinical symptomatology.
Ideally, such a marker also would be used to monitor
the effectiveness of treatment on the clinical
manifestations of Alzheimer’s disease, would show
specificity for Alzheimer’s disease with few false
positives (1.e., a diagnosis of Alzheimer’s disease in
someone who does not have the disease), and would be
convenient and inexpensive enough to justify wide use,
including screening (Cummings & Jeste, 1999).
Discovery of such a marker is clearly a research
priority.

Behavioral Symptoms

Alzheimer’s disease is associated with a range of
symptoms evident in cognition and other behaviors;
these include, most notably, psychosis, depression,
agitation, and wandering. Other behavioral symptoms
of Alzheimer’s disease include insomnia; incontinence;
catastrophic verbal, emotional, or physical outbursts;
sexual disorders; loss. Behavioral
symptoms, however, are not required for diagnosis.
While behavioral symptoms have received less
attention than cognitive symptoms, they have serious
ramifications: patient and caregiver distress, premature
institutionalization, and significant compromise of the
quality of life of patients and their families (Rabins et
al., 1982; Ferris et al., 1987; Finkel et al., 1996; Kaufer
etal., 1998). Alzheimer’s disease, especially behavioral
symptoms, appears to place patients at risk for abuse by
caregivers (Coyne et al., 1993).

Behavioral symptoms occur at some point during
the disease with high frequencies: 30 to 50 percent of
individuals with Alzheimer’s disease experience
delusions, 10 to 25 percent have hallucinations, and 40
to 50 percent have symptoms of depression (Mega et
al., 1996; Cummings et al., 1998b). Patients with
psychotic disorders have greater cognitive impairment,
more rapidly progressive dementia, and greater frontal
and temporal dysfunction on functional brain imaging
(Jeste et al., 1992: Sultzer et al., 1995). Patients with
psychotic illness also exhibit agitation,
depression, wandering, anger, personality change,

and weight

more

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Older Adults and Mental Health

family or marital problems, and lack of self-care
(Rockwell et al., 1994). Depression in patients with
Alzheimer’s disease accelerates loss of functioning in
everyday activities (Ritchie et al., 1998). Even modest
reduction in behavioral symptoms can produce
substantial improvements in functioning and quality of
life.

Course

Patients with Alzheimer’s disease experience a gradual
decline in functioning throughout the course of their
illness. Typically, a loss of 4 points per year on the
Mini Mental Status Exam is detected, but there is a
great deal of heterogeneity in the rate of decline
(Olichney et al., 1998). Memory dysfunction is not only
the most prominent deficit in dementia but also is the
most likely presenting symptom. Deficits in language
and executive functioning, while common in the
disorder, tend to manifest later in its course (Locascio
et al., 1995). Depression is prevalent in the early stages
of dementia and appears to recede with functional
decline (Locascio et al., 1995). Although this may
reflect decreasing awareness of depression by the
patient, it also could reflect inadequate detection of
depression by health professionals. Behavioral
symptoms, such as agitation, seem to be more prevalent
in the later stages of Alzheimer’s disease (Patterson &
Bolger, 1994); however, psychosis has been observed
in patients with varying levels of severity (Borson &
Raskind, 1997). The duration of illness, from onset of
symptoms to death, averages 8 to 10 years (DSM-IV).

Prevalence and Incidence

Alzheimer’s disease is a prominent disorder of old age:
8 to 15 percent of people over age 65 have Alzheimer’s
disease (Ritchie & Kildea, 1995). The prevalence of
dementia (most of which is accounted for by
Alzheimer’s disease) nearly doubles with every 5 years
of age after age 60 (Jorm et al., 1987). Although more
women than men have Alzheimer’s disease (that is, the
prevalence of the disease appears to be higher among
women), this may reflect women’s longer life spans,
because studies do not show marked gender differences
in incidence rates (Lebowitz et al., 1998). Incidence
Mental Health: A Report of the Surgeon General

studies also reveal age-related increases in Alzheimer’s
disease (Breteler et al., 1992; Paykel et al., 1994;
Hebert et al., 1995; Johansson & Zarit, 1995;
Aevarsson & Skoog, 1996). One percent of those age
60 to 64 are affected with dementia; 2 percent of those
age 65 to 69; 4 percent of those age 70 to 74; 8 percent
of those 75 to 79; 16 percent of those age 80 to 84; and
30 to 45 percent of those age 85 and older (Jorm et al.,
1987; Evans et al., 1989).

The “graying of America” is likely to result in an
increase in the number of individuals with Alzheimer’s
disease, yet shifts in the composition of the affected
population also are anticipated. Increased education is
correlated with a lower frequency of Alzheimer’s
disease (Hill et al., 1993; Katzman, 1993; Stern et al.,
1994), and future cohorts are expected to have attained
greater levels of education. For example, the portion of
those currently 75 years of age and older—those most
vulnerable to Alzheimer’s disease—with at least a high
school education is 58.7 percent. Of those currently age
60 to 64 who will enter the period of maximum
vulnerability by the year 2010, 75.5 percent have at
least a high school education. A higher educational
level among the at-risk cohort may delay the onset of
Alzheimer’s disease and thereby decrease the overall
frequency of Alzheimer’s disease (by decreasing the
number of individuals who live long enough to enter
the period of maximum vulnerability). However, this
trend may be counterbalanced or overtaken by greater
longevity and longer survival of affected individuals.
Specifically, improvements in general health and health
care may lengthen the survival of dementia patients,
increasing the number of severely affected patients and
raising their level of medical comorbidity. Similarly,
through dissemination of information to patients and
clinicians, better detection, especially of early-stage
patients, is expected. Increased use of putative
protective agents, such as vitamin E, also may increase
the number of patients in the middle phases of the
illness (Cummings & Jeste, 1999).

Cost
The growing number of patients with Alzheimer’s
disease is likely to have serious public health and

360

economic consequences. Direct and indirect costs for
medical and long-term care, home care, and loss of
productivity for caregivers are estimated at nearly $100
billion each year (Ernst & Hay, 1994; National Institute
on Aging, 1996). This economic burden is borne mostly
by families of patients with Alzheimer’s disease,
although a significant portion of the direct costs is
covered by Medicare, Medicaid, and private insurance
companies. Costs are especially high among patients
with behavioral symptoms, who often require earlier or
more frequent institutionalization (Ferris et al., 1987).

Etiology of Alzheimer’s Disease

Biological Factors
The etiology of Alzheimer’s disease is still

incompletely understood yet is thought to entail a
complex combination of genetic and environmental
factors. Genetic factors appear to play a significant role
in the pathogenesis of Alzheimer’s disease. In the
familial form, Alzheimer’s disease is caused by
mutations in chromosomes 21, 14, and 1 and is
transmitted in an autosomal dominant mode. Each of
these mutations appears to result in overproduction of
the protein found in neuritic plaques, B-amyloid. Onset
of the familial form is usually early, but the course and
nature of the disorder appear to be influenced by
environmental factors (Cummings et al., 1998b).
However, the familial form accounts for only a small
proportion of cases of Alzheimer’s disease (less than 5
percent) (Cummings et al., 1998b).

Approximately 50 percent of individuals with a
family history of Alzheimer’s disease, if followed into
their 80s and 90s, develop the disorder (Mohs et al.,
1987). Certain genotypes (the pattern of genetic
inheritance in an individual) appear to confer risk for
the more common late-onset form of Alzheimer’s
disease. For example, the ApoE-e4 allele* on
chromosome 19, which increases the deposition of
B-amyloid, has been shown to increase risk for
developing Alzheimer’s disease (Corder et al., 1993).

 

4 An allele is a variant form of a gene.
Other possible candidate genes are under study (Kang
et al., 1997).

Other biological risk factors for the development of
Alzheimer’s disease include aging and cognitive
capacities (Cummings et al., 1998b). The mechanisms
by which these traits confer increased risk have not yet
been fully determined; however, several neurobiologic
changes related to normal aging of the brain may play
arole in the increased risk for Alzheimer’s disease with
increasing age. These include neuron and synaptic loss,
decreased dendritic span, decreased size and density of
neurons in the nucleus basalis of Meynert, and lower
cortical acetylcholine levels (Cummings et al., 1998b).
These findings, as well as extrapolations from the
prevalence and incidence. curves for Alzheimer’s
disease, have led some to suggest that most individuals
would eventually develop Alzheimer’s disease if the
human life span was extended (for example, to age
120).

Protective Factors

Several protective factors that delay the onset of
Alzheimer’s disease have been identified. Genetic
endowment with the ApoE-e2 allele decreases the risk
for Alzheimer’s disease (Duara et al., 1996), although
the mechanism of action is not yet fully understood.
Higher educational level also is related to delayed onset
of Alzheimer’s disease (Stern et al., 1994; Callahan et
al., 1996a). The use of certain medications, such as
nonsteroidal anti-inflammatory drugs (Andersen et al.,
1995: McGeer et al., 1996) and estrogen replacement
therapy (Paganini-Hill & Henderson, 1994), may delay
onset of the disorder. Vitamin E and the drug selegiline
(also known as deprenyl) appear to delay the
occurrence of important milestones in the course of
Alzheimer’s disease, including nursing home
placement, severe functional impairments even as the
disease progresses, and death (Sano et al. 1997).

The mechanism of action of these protective agents
is not fully understood but is thought to counter the
deleterious action of oxidative stress (via antioxidants
such as vitamin E or estrogen) (Behl et al., 1995) or the
action of inflammatory mediators associated with

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Older Adults and Mental Health

plaque formation (via anti-inflammatories) (Mrak et al..
1995).

Histopathology
The pathophysiology of Alzheimer’s disease appears to
be linked to the histopathologic changes in Alzheimer’s
disease, which include neuritic plaques, neurofibrillary
tangles, synaptic loss, hippocampal granulovacuolar
degeneration, and amyloid angiopathy. Most of the
genetic and epigenetic risk factors have been related in
some way to B-amyloid. Thus, the generation of
B-amyloid peptide is increasingly regarded as the
central pathological event in Alzheimer’s disease
(Cummings et al., 1998b; Hardy & Higgins, 1992).
Effective intervention for Alzheimer’s disease may
involve interfering with the multiple steps within the
putative Alzheimer’s disease pathogenetic cascade.
Targets of intervention include reducing B-amyloid
generation from the amyloid precursor protein,
decreasing B-amyloid aggregation and formation of
beta-pleated sheets, interfering with
amyloid-related neurotoxicity. In addition, therapies
could involve interruption of neuronal cell death,

and

inhibition of the inflammatory response occurring in
neuritic plaques, use of growth factors and hormonal
therapies, and replenishment of deficient neurotrans-
mitters. Because complete blockade of steps within the
B-amyloid cascade may interfere with normal cerebral
metabolic processes, efficacious interventions could
involve partial interruptions (Cummings & Jeste,
1999).

Researchers in the molecular neuroscience of
Alzheimer’s disease are exploring a number of
important aspects of pathophysiology and etiology. As
understanding of mechanisms of cell death and
neuronal degeneration increases, new opportunities for
the development of therapeutics are expected to emerge
(National Institute on Aging, 1996).

Role of Acetylcholine
Loss of the neurotransmitter acetylcholine also is

thought to play an instrumental role in the pathogenesis
of Alzheimer’s disease. of
Alzheimer’s disease consistently have demonstrated the

Postmortem studies
Mental Health: A Report of the Surgeon General

loss of basal forebrain and cortical cholinergic neurons
and the depletion of choline acetyltransferase, the
enzyme responsible for acetylcholine synthesis
(Mesulam, 1996). The degree of this central cholinergic
deficit is correlated with the severity of dementia,
which has led to the “cholinergic hypothesis” of
cognitive deficits in Alzheimer’s disease. This
hypothesis has led, in turn, to promising clinical
interventions discussed below. It should be
emphasized, however, that acetylcholine is not
necessarily the only neurotransmitter involved in
Alzheimer’s disease: research has not ruled out the
contributions of other substances in pathogenesis of the
disease.

Pharmacological Treatment of Alzheimer’s
Disease

Pharmacological treatment of Alzheimer’s disease isa
promising new focus for interventions. A delay in onset
of Alzheimer’s disease for 5 years might reduce the
prevalence of Alzheimer’s disease by as much as
one-half (Breitner, 1991). In other words, to influence
the prevalence of Alzheimer’s disease, it may be
necessary only to delay the onset of the disease to the
point where mortality from other sources supersedes
the incidence of Alzheimer’s disease. Thus, a central
goal in Alzheimer’s disease treatment research is the
identification of agents that prevent the occurrence,
defer the onset, slow the progression, or improve the
symptoms of Alzheimer’s disease. Progress has been
made in this research arena, with several agents
showing beneficial effects in Alzheimer’s disease.

Acetylcholinesterase Inhibitors

Recent attempts to treat Alzheimer’s disease have
focused on enhancing acetylcholine function, using
either cholinergic receptor agonists (e.g., nicotine) or,
most commonly, using acetylcholinesterase (AChE)
inhibitors (e.g., physostigmine, velnacrine, tacrine,
donepezil, or metrifonate) to increase the availability of
acetylcholine in the synaptic cleft. Such treatments
have generally been beneficial in ameliorating global
cognitive dysfunction and, more specifically, are most
effective in improving attention (Norberg, 1996;

362

Lawrence & Sahakian, 1998). Amelioration of learning
and memory impairments, the most prominent
cognitive deficits in Alzheimer’s disease, have been
found less consistently (Lawrence & Sahakian, 1998),
although some studies have shown improvements
(Thal, 1996). It has been argued that failure of AChE
inhibitors and nicotine to improve learning and memory
may be due to high levels of neurodegeneration in the
medial temporal lobe (Lawrence & Sahakian, 1998).
Neuronal degeneration in this region of the brain leaves
neurons impervious to the benefits of some types of
replacement therapy. Detailed, neuropsychological
studies of the effects of the newer cognitive enhancers,
donepezil and metrifonate (an experimental drug), have
not yet been published, but global cognitive functioning
appears to be improved with both compounds
(Cummings et al., 1998a; Rogers et al., 1998).
Treatment with these AChE inhibitors also appears to
benefit noncognitive symptoms in Alzheimer’s disease,
such as delusions (Raskind et al., 1997) and behavioral
symptoms (Kaufer et al., 1996; Morris et al., 1998).

Treatment of Behavioral Symptoms

The behavioral symptoms of Alzheimer’s disease have
received less therapeutic attention than cognitive
symptoms. Few double-blind, placebo-controlled
studies of medications for behavioral symptoms of
Alzheimer’s disease have been performed. For the most
part, behavioral symptoms have been treated with
medications developed for primary psychiatric
symptoms. The emergence of new antipsychotic and
antidepressant medications requires that these agents be
studied specifically for Alzheimer’s disease. The
observation that cholinergic agents used to enhance
cognition in Alzheimer’s disease may have beneficial
behavioral effects also needs further exploration
(Kaufer et al., 1996; Bodick et al., 1997; Raskind et al.,
1997).

One area that has been studied is the treatment of
depression in Alzheimer’s disease. Treatment with the
antidepressants paroxetine and imipramine has been
shown to be effective in depressed Alzheimer’s disease
patients (Reifler et al., 1989; Katona et al., 1998).
Treatment may not only be effective for relieving
depressive symptoms but also for its potential to
improve functional ability (Pearson et al., 1989; Ritchie
et al., 1998).

Several challenges are encountered with the
pharmacological treatment of Alzheimer’s disease.
First, because of the cognitive deficits that are the
hallmark of dementia, caregiver assistance is crucial for
compliance with pharmacotherapy regimens. Second,
although the current pharmacotherapies are likely to be
most useful if administered early in the course of the
disorder, early detection of Alzheimer’s disease is
encumbered by the lack of a verified biological or
biobehavioral marker. Third, little is currently known
about the optimal duration of treatment with pharmaco-
therapies. .
Psychosocial Treatment of Alzheimer’s
Disease Patients and Caregivers
Psychosocial interventions are extremely important in
Alzheimer’s disease. Although there has been some
research on preserving cognition, most research has
focused on treating patients’ behavioral symptoms and
relieving caregiver burden. Support for caregivers is
crucial because caregivers of older patients are at risk
for depression, anxiety, and somatic problems (Light &
Lebowitz, 1991). Psychosocial interventions targeted
either at patients or family caregivers can improve
outcomes for patients and caregivers alike.

Psychosocial techniques developed for use in
patients with cognitive impairment may be helpful in
Alzheimer’s disease. Strengthening ways to deal with
cognitive losses may reduce functional limitations for
patients with the early stages of Alzheimer’s disease,
before multiple brain systems become compromised.
For example. training in the use of memory aids, such
as mnemonics, computerized recall devices, or copious
use of notetaking, may assist patients with mild
dementia. While initial research on the use of cognitive
rehabilitation in dementia is promising, further studies
are needed (Pliskin et al., 1996).

Of the behavioral symptoms experienced by
patients with Alzheimer’s disease, depression and
anxiety occur most frequently during the early stages of
dementing disorders, whereas psychotic symptoms and

363

Older Adults and Mental Health

aggressive behavior occur during later stages
(Alexopoulos & Abrams, 1991; Devanandetal., 1997).
Early evidence suggested that cognitive and behavioral
therapies are beneficial in treating depressed older
patients with dementia (Teri & Gallagher-Thompson,
1991; Teri & Uomoto, 1991). Cognitive therapy, seen
as more promising for the early stages of dementia,
strives to help patients cope with depression by
reducing cognitive distortions and by fostering more
adaptive perceptions. Behavioral therapy, seen as more
promising for more moderately or severely affected
adults with dementia, targets family caregivers
directly—and patients indirectly—by helping care-
givers identify, plan, and increase pleasant activities for
the patient, such as taking a walk, designed to improve
their mood (Teri & Gallagher-Thompson, 1991).

Further affirmation for behavioral therapy for
depression of patients with Alzheimer’s disease
recently was provided by acontrolled clinical trial. The
trial compared two types of behavioral therapy with a
typical care condition and a waiting list control. One of
the behavioral therapies targeted family caregivers to
help them increase pleasant events for the patients,
while the other gave caregivers more latitude in
choosing which behavioral problem-solving strategies
to deal with patients’ depression. Both behavioral
therapies led to significant improvement in patients’
depressive symptoms. Moreover, the caregivers also
showed significant improvement in their own
depressive symptoms (Teri et al., 1997).

For alleviating caregiver and family distress, a
broad array of psychosocial interventions was assessed
in a meta-analysis of 18 studies (Knight et al., 1993).
The interventions included psychoeducation, support,
cognitive-behavioral techniques, self-help, and respite
care. Individual and respite programs were found
moderately effective at reducing caregiver burden and
dysphoria, but group
marginally effective. Subsequent research buttressed

interventions were only
the utility of adult day care in reducing caregivers’
stress and depression and in enhancing their well-being
(Zarit et al., 1998). Beyond direct benefits to
caregivers, support interventions also have benefited
patients and have saved resources. For example, a
Mental Health: A Report of the Surgeon General

psychosocial intervention—individual and family
counseling plus support group participation—aimed at
caregiving spouses was shown to delay institutionaliza-
tion of patients with dementia by almost a year in a
randomized trial (Mittelman et al., 1993, 1996).
Targeted behavioral techniques also improved the
quality of caregivers’ sleep (McCurry et al., 1996),
whereas psychoeducation and family support appeared
to promote better patient management (Zarit et al.,
1985).

The virtues of psychosocial interventions also
extend to patients with Alzheimer’s disease in nursing
homes. Until the late 1980s, nursing homes employed
restraints and sedatives and other medications to
control behavioral symptoms in patients with dementia.
But the untoward consequences, in terms of injuries
from physical restraints” and increased patient
disorientation, led to nursing home reform practices
required by the Federal Nursing Home Reform Act of
the Omnibus Budget Reconciliation Act of 1987
(Cohen & Cairl, 1996). In the past few years, a range of
behavioral interventions for nursing home staff has
been shown to be effective in improving behavioral
symptoms of Alzheimer’s disease, such as incontinence
(Burgio et al., 1990; Schnelle et al., 1995), dressing
problems (Beck et al., 1997), and verbal agitation
(Burgio et al., 1996; Cohen-Mansfield & Werner,
1997). A major problem is that interventions are not
maintained or implemented correctly by nursing home
staff (Schnelle et al., 1998). New approaches seek to
teach and maintain behavior management skills of
nursing home assistants through a formal staff
management system (Barinaga, 1998; Stevens et al.,
1998).

Other Mental Disorders in Older
Adults

Anxiety Disorders

Prevalence of Anxiety

Anxiety symptoms and syndromes are important but
understudied conditions in older adults. Overall,
community-based prevalence estimates indicate that

about 11.4 percent of adults aged 55 years and older
meet criteria for an anxiety disorder in 1 year (Flint,
1994; Table 5-1). Phobic anxiety disorders are among
the most common mental disturbances in late life
according to the ECA study (Table 5-1). Prevalence
studies of panic disorder (0.5 percent) and
obsessive-compulsive disorder (1.5 percent) in older
samples reveal low rates (Table 5-1) (Copeland et al.,
1987a; Copeland et al., 1987b; Bland et al., 1988;
Lindesay et al., 1989). Although the National
Comorbidity Survey did not cover this age range, and
the ECA did not include this disorder, other studies
showed a prevalence of generalized anxiety disorder in
older adults ranging from 1.1 percent to 17.3 percent
higher than that reported for panic disorder or
obsessive-compulsive disorder (Copeland etal., 1987a;
Skoog, 1993). Worry or “nervous tension,” rather than
specific anxiety syndromes may be more important in
older people. Anxiety symptoms that do not fulfill the
criteria for specific syndromes are reported in up to 17
percent of older men and 21 percent of older women
(Himmelfarb & Murrell, 1984).

In addition, some disorders that have received less
study in older adults may become more important in the
near future. For example, post-traumatic stress disorder
(PTSD) is expected to assume increasing importance as
Vietnam veterans age. At 19 years after combat
exposure, this cohort of veterans has been found to
have a PTSD prevalence of 15 percent (cited in
McFarlane & Yehuda, 1996). As affected patients age,
there is a continuing need for services. In addition,
research has shown that PTSD can manifest for the first
time long after the traumatic event (Aarts & Op den
Velde, 1996), raising the specter that even more
patients will be identified in the future.

Treatment of Anxiety
The effectiveness of benzodiazepines in reducing acute

anxiety has been demonstrated in younger and older
patients, and no differences in the effectiveness have
been documented among the various benzodiazepines.
Some research suggests that benzodiazepines are
marginally effective at best in treating chronic anxiety
in older patients (Smith et al., 1995).
The half-life of certain benzodiazepines and their
metabolites may be significantly extended in older
patients (particularly for the compounds with long
half-life). If taken over extended periods, even
short-acting benzodiazepines tend to accumulate in
older individuals. Thus, it is generally recommended
that any use of benzodiazepines be limited to discrete
periods (less than 6 months) and that long-acting
compounds be avoided in this population. On the other
hand, use of short-acting compounds may predispose
older patients to withdrawal symptoms (Salzman,
1991).

Side effects of benzodiazepines may include
drowsiness, fatigue, psychomotor impairment, memory
or other cognitive impairment, confusion, paradoxical
reactions, depression, respiratory problems, abuse or
dependence problems, and withdrawal reactions.
Benzodiazepine toxicity in older patients includes
sedation, cerebellar impairment (manifested by ataxia,
dysarthria, incoordination, or unsteadiness), cognitive
impairment, and psychomotor impairment (Salzman,
1991). Psychomotor impairment from benzodiazepines
can have severe consequences, leading to impaired
driver skills and motor vehicle crashes (Barbone et al.,
1998) and falls (Caramel et al., 1998).

Buspirone is an anxiolytic (antianxiety) agent that
is chemically and pharmacologically distinct from
benzodiazepines. Controlled studies with younger
patients suggest that the efficacy of buspirone is
comparable to that of the benzodiazepines. It also has
proven effective in studies of older patients
(Napoliello, 1986; Robinson et al., 1988; Bohm et al.,
1990). On the other hand, buspirone may require up to
4 weeks to take effect, so initial augmentation with
another antianxiety medication may be necessary for
some acutely anxious patients (Sheikh, 1994).
Significant adverse reactions to buspirone are found in
20 to 30 percent of anxious older patients (Napoliello,
1986; Robinson et al., 1988). The most frequent side
effects include gastrointestinal symptoms, dizziness,
headache, nausea/vomiting,
uneasiness, fatigue, and diarrhea. Still, buspirone may
be less sedating than benzodiazepines (Salzman, 1991;
Seidel et al., 1995).

sleep disturbance,

365

Older Adults and Mental Health

Although the efficacy of antidepressants for the
treatment of anxiety disorders in late life has not been
studied, current patterns of practice are informed by the
efficacy literature in adults in midlife (see Chapter 4).

Schizophrenia in Late Life

Although schizophrenia is commonly thought of as an
illness of young adulthood, it can both extend into and
first appear in later life. Diagnostic criteria for
schizophrenia are the same across the life span, and
DSM-IV places no restrictions on age of onset for a
diagnosis to be made. Symptoms include delusions,
hallucinations, disorganized speech, disorganized or
catatonic behavior (the so-called “‘positive” symptoms),
as well as affective flattening, alogia, or avolition® (the
so-called “negative” symptoms). Symptoms must cause
significant social or occupational dysfunction, must not
be accompanied by prominent mood symptoms, and
must not be uniquely associated with substance use.

Prevalence and Cost

One-year prevalence of schizophrenia among those 65
years or older is reportedly only around 0.6 percent,
about one-half the 1-year prevalence of the 1.3 percent
that is estimated for the population aged 18 to 54
(Tables 5-1 and 4-1).

The economic burden of late-life schizophrenia is
high. A study using records from a large California
county found the mean cost of mental health service for
schizophrenia to be significantly higher than that for
other mental disorders (Cuffel et al., 1996); the mean
expenditure among the oldest with
schizophrenia (> 74 years old) was comparable to that
among the youngest patients (age 18 to 29). While
long-term studies have shown that use of nursing

patients

homes, state hospitals, and general hospital care by
patients with all mental disorder diagnoses has declined
in recent decades, the rate of decline is lower for older
patients with schizophrenia (Kramer et al., 1973;
Redick et al., 1977). The high cost of these settings

 

 

5 Alogia refers to poverty of speech, and avolition refers to lack of
goal-directed behavior.
Mental Health: A Report of the Surgeon General

contributes to the greater economic burden associated
with late-life schizophrenia.

Late-Onset Schizophrenia

Studies have compared patients with late onset (age at
onset 45 years or older) and similarly aged patients
with earlier onset of schizophrenia (Jeste et al., 1997),
both were very similar in terms of genetic risk, clinical
presentation, treatment response. and course.

Among key differences between the groups,
patients with late-onset schizophrenia were more likely
to be women in whom paranoia was a predominant
feature of the Patients with late-onset
schizophrenia had less impairment in the specific
neurocognitive areas of learning and abstraction/
cognitive flexibility and required lower doses of
neuroleptic medications for management of their
psychotic symptoms. These and other differences
between patients with early- and late-onset illness
suggest that there might be neurobiologic differences
mediating the onset of symptoms (DeLisi, 1992; Jeste
et al., in press).

illness.

Course and Recovery

The original conception of “dementia praecox,” the
early term for schizophrenia, emphasized progressive
decline (Kraepelin, 1971); however, it now appears that
Kraepelin’s picture captures the outcome for a small
percentage of patients, while one-half to two-thirds
significantly improve or recover with treatment and
psychosocial rehabilitation (Chapter 4). Although the
rates of full remission remain unclear, some patients
with schizophrenia demonstrate remarkable recovery
after many years of chronic dysfunction (Nasar, 1998).
Research suggests that a factor in better long-term
outcome is early intervention with antipsychotic
medications during a patient’s first psychotic episode
(See Chapter 4).

A recent cross-sectional study that compared
middle-aged with older patients, all of whom lived in
community settings, found some similarities and
differences (Eyler-Zorrilla et al., 1999). The older
patients experienced less severe symptoms overall and
‘were on lower daily doses of neuroleptics than middle-

366

aged patients who were similar in demographic,
clinical, functional, and broad cognitive measures. In
addition, positive symptoms were less prominent (or
equivalent) in the older group, depending on the
measure used. Negative symptoms were more
prominent (or equivalent) in the older group, and older
patients scored more poorly on severity of dyskinesia.
Older patients were impaired relative to middle-aged
ones on two measures of global cognitive function.
This finding, however, appeared to reflect a normal
degree of decline from an impaired baseline, as the
degree of change in cognitive function with age in the
patient group was equivalent to that seen in the
comparison group.

A recent study used the Direct Assessment of
Functional Status scale (DAFS) (Loewenstein et al.,
1989) to compare the everyday living skills of
middle-aged and older adults with schizophrenia with
those of people without schizophrenia of similar ages
(Klapow et al, 1997). The patients exhibited
significantly more functional limitations than the
controls did across most DAFS subscales. In another
recent study that used a measure of overall disease
impact, the Quality of Well-Being Scale, older
outpatients with schizophrenia manifested significantly
lower quality of well-being than did comparison
subjects, and their scores were slightly worse than
those of ambulatory AIDS patients (Patterson et al.,
1996).

Thus, while schizophrenia may be less universally
deteriorating than previously has been assumed, older
patients with the disorder continue nonetheless to
exhibit functional deficits that warrant research and
clinical attention.

Etiology of Late-Onset Schizophrenia

Recent studies support a neurodevelopmental view of
late-onset schizophrenia (Jeste et al., 1997). Equivalent
degrees of childhood maladjustment have been found
in patients with late-onset schizophrenia and early-
onset schizophrenia, for example, suggesting that some
liability for the disorder exists early in life. Equivalent
degrees of minor physical anomalies in patients with
late-onset schizophrenia and early-onset schizophrenia
suggest the presence of developmental defects in both
groups (Lohr et al., 1997). The presence of a genetic
contribution to late-onset and early-onset schizophrenia
is evident in increased rates of schizophrenia among
first-degree relatives (Rokhlina, 1975; Castle &
Howard, 1992; Castle et al., 1997).

If late-onset schizophrenia is neurodevelopmental
in origin, an explanation for the delayed onset may be
that late-onset schizophrenia is a less severe form of the
disorder and, as such, is less likely to manifest early in
life. Recent research suggests that in several arenas—
for example, neuropsychological impairments in
learning, retrieval, abstraction, and semantic memory as
well as electroencephalogram abnormalities—the
deficits of patients with late-onset schizophrenia are
less severe (Heaton et al,, 1994; Jeste et al., 1995b;
Olichney et al., 1995, 1996; Paulsen et al., 1995, 1996).
Also, negative symptoms are less pronounced and
neuroleptic doses are lower in patients with late-onset
schizophrenia (Jeste et al., 1995b). The etiology and
onset of schizophrenia in younger adults often are
explained by a diathesis-stress model in which there is
a genetic vulnerability in combination with an
environmental insult (such as obstetric complications),
with onset triggered by maturational changes or life
events that stress a developmentally damaged brain
(Feinberg, 1983; Weinberger, 1987; Wyatt. 1996).
Under this multiple insult model, patients with late-
onset schizophrenia may have had fewer insults and
thus have a delayed onset. An alternative or
complementary explanation for the delayed onset in
late-onset schizophrenia is the possibility that these
patients possess protective features that cushion the
blow of any additional insults. The preponderance of
women among patients with late-onset schizophrenia
has fueled hypotheses that estrogen plays a protective
role.

The view of late-onset schizophrenia as a less
severe form of schizophrenia, in which the delayed
onset results from fewer detrimental insults or the
presence of protective factors, suggests a continuous
relationship between age at onset and severity of
liability. An alternative view is that late-onset
schizophrenia is a distinct neurobiological subtype of

367

Older Adults and Mental Health

schizophrenia. The preponderance of women and of
paranoid patients seen late-onset
schizophrenia supports this view. These two etiologic
theories of late-onset schizophrenia call for further
research.

subtype in

Treatment of Schizophrenia in Late Life
Pharmacological treatment of schizophrenia in late life

presents some unique challenges. Conventional
neuroleptic agents, such as haloperidol, have proven
effective in managing the “positive symptoms” (such as
delusions and hallucinations) of many older patients,
but these medications have a high risk of potentially
disabling and persistent side effects, such as tardive
dyskinesia (Jeste et al., in press). The cumulative
annual incidence of tardive dyskinesia among older
outpatients (29 percent) treated with relatively low
daily doses of conventional antipsychotic medications
is higher than that reported in younger adults (Jeste et
al., in press).

Recent years have witnessed promising advances in
the management of schizophrenia. Studies with mostly
younger schizophrenia patients suggest that the newer
antipsychotics,
risperidone, olanzapine, and quetiapine, may be
effective
unresponsive to traditional neuroleptics. They also are

“atypical” such as clozapine,

in treating those patients previously
associated with a lower risk of extrapyramidal
symptoms and tardive dyskinesia (Jeste et al., in press).
Moreover, the newer medications may be more
effective in treating negative symptoms and may even
yield partial improvement in certain neurocognitive
deficits associated with this disorder (Green et al..
1997).

The foremost barriers to the widespread use of
atypical antipsychotic medications in older adults are
(1) the lack of large-scale studies to demonstrate the
effectiveness and safety of these medications in older
patients with multiple medical conditions, and (2) the
higher cost of these medications relative to traditional

neuroleptics (Thomas & Lewis, 1998).
Mental Health: A Report of the Surgeon General

Alcohol and Substance Use Disorders in
Older Adults
Older people are not immune to the problems
associated with improper use of alcohol and drugs, but
as a rule, misuse of alcohol and prescription
medications appears to be a more common problem
among older adults than abuse of illicit drugs. Still,
because few studies of the incidence and prevalence of
substance abuse have focused on older adults—and
because those few were beset by methodological
problems—the popular perception may be misleading.
A persistent research problem has been that
diagnostic criteria for substance abuse were developed
and validated on young and middle-aged adults. For
example, DSM-IV criteria include increased tolerance
to the effects of the substance, which results in
increased consumption over time; yet, changes in
pharmacokinetics and physiology may alter drug
tolerance in older adults. Decreased tolerance to
alcohol among older individuals may lead to decreased
consumption of alcohol with no apparent reduction in
intoxication. Criteria that relate to the impact of drug
use on typical tasks of young and middle adulthood,
such as school and work performance or child rearing,
may be largely irrelevant to older adults, who often live
alone and are retired. Thus, abuse and dependence
among older adults may be underestimated (Ellor &
Kurz, 1982; Miller et al., 1991; King et al., 1994).

Epidemiology

Alcohol Abuse and Dependence

The prevalence of heavy drinking (12 to 21 drinks per
week) in older adults is estimated at 3 to 9 percent
(Liberto et al., 1992). One-month prevalence estimates
of alcohol abuse and dependence in this group are
much lower, ranging from 0.9 percent (Regier et al.,
1988) to 2.2 percent (Bailey et al., 1965). Alcohol
abuse and dependence are approximately four times
more common among men than women (1.2 percent vs.
0.3 percent) ages 65 and older (Grant et al., 1994).
Although lifetime prevalence rates for alcoholism are
higher for white men and women between ages 18 and
29, African American men and women have higher

368

rates among those 65 years and older. For Hispanics,
men had rates between those of whites and African
Americans. Hispanic females had a much lower rate
than that for whites and African Americans (Helzer et
al., 1991). Longitudinal studies suggest variously that
alcohol consumption decreases with age (Temple &
Leino, 1989; Adams et al., 1990), remains stable
(Ekerdt et al., 1989), or increases (Gordon & Kannel,
1983), but it is anticipated that alcohol abuse or
dependence will increase as the baby boomers age,
since that cohort has a greater history of alcohol
consumption than current cohorts of older adults (Reid
& Anderson, 1997).

Misuse of Prescription and Over-the-Counter
Medications

Older persons use prescription drugs approximately
three times as frequently as the general population
(Special Committee on Aging, 1987), and the use of
over-the-counter medications by this group is even
more extensive (Kofoed, 1984). Annual estimated
expenditures on prescription drugs by older adults in
the United States are $15 billion annually, a fourfold
greater per capita expenditure on medications
compared with that of younger individuals (Anderson
et al., 1993; Jeste & Palmer, 1998). Not surprisingly,
substance abuse problems in older adults frequently
may result from the misuse—that is, underuse, overuse,
or erratic use—of such medications; such patterns of
use may be due partly to difficulties older individuals
have with following and reading prescriptions (Devor
et al., 1994). In its extreme form, such misuse of drugs
may become drug abuse (Ellor & Kurz, 1982;
DSM-IV).

Research studies that have relied on medical
records review show consistently that alcohol abuse
and dependence are significantly more common than
other forms of substance abuse and dependence
(Finlayson & Davis, 1994; Moos et al., 1994). Yet
prescription drug dependence is not uncommon and, as
Finlayson and Davis (1994) found, the greatest risk
factor for abuse of prescription medication was being
female. This finding is supported by other studies
showing that older women are more likely than men to
visit physicians and to be prescribed psychoactive
drugs (Cafferata et al., 1983; Baum et al., 1984; Mos-
sey & Shapiro, 1985; Adams et al., 1990). In contrast,
an analysis of data from the National Household
Survey on Drug Abuse concluded that older men were
more likely than women to report use of sedatives,
tranquilizers, and stimulants (Robins & Clayton, 1989).
Older adults of both sexes are at risk for analgesic
abuse, which can culminate in various nephropathies
(Elseviers & De Broe, 1998).

Benzodiazepine use represents an area of particular
concern for older adults given the frequency with
which these medications are prescribed at
inappropriately high doses (Shorr et al., 1990) and for
excessive periods of time. A national survey of
approximately 3,000 community-dwelling persons
found that older persons were overrepresented among
the 1.6 percent who had taken benzodiazepines daily
for 1 year or longer (71 percent > 50 years; 33 percent
> 65 years of age) (Mellinger et al., 1984).
Benzodiazepine users were more likely to be older,
white, female, less educated, separated/divorced, to
have experienced increased stressful life events, and to
have a psychiatric diagnosis (Swartz et al., 1991).

Illicit Drug Abuse and Dependence
In contrast to alcohol and licit medications, older adults

infrequently use illicit drugs. Less than 0.1 percent of
older individuals in the Epidemiologic Catchment Area
study met DSM-III (American Psychiatric Association,
1980) criteria for drug abuse/dependence during the
previous month (Regier et al., 1988). This compared
with a l-month prevalence rate of 3.5 percent among
18-to 24-year-olds. ECA data further suggest a lifetime
prevalence of illegal drug use of 1.6 percent for persons
older than 65 years (Anthony & Helzer, 1991).

The development of addiction to illict drugs after
young adulthood is rare, while mortality is high
(Atkinson et al., 1992). For example, over 27 percent of
heroin addicts died during a 24-year period (Hser et al.,
1993), and 5.6 percent of deaths associated with heroin
or morphine use were among persons older than 55
(National Institute on Drug Abuse, 1992).

369

Older Adults and Mental Health

As is projected to occur with trends in alcohol
consumption, the low prevalence of older adults’ drug
use and abuse in the late 1990s may change as the baby
boomers age. Annual “snapshot” data extrapolated
from the National Household Survey on Drug Abuse,
which has been conducted since 1971, afford a glimpse
of trends. Patterson and Jeste (1999) recently compared
prevalence estimates of those born during the baby
boom with an older (> 35 years) non-baby-boomer
cohort. The difference between baby boomers and the
previous cohort translated in 1996 into an excess of
approximately 1.1 million individuals using drugs.
Their excess drug use, combined with their sheer
numbers, means that more drug use is expected as this
cohort ages, placing greater pressures on treatment
programs and other resources.

Projections also suggest that the costs of alcohol
and substance abuse are likely to rise in the near future.
Across age ranges, drug abuse and alcohol abuse have
been estimated to cost over $109.8 billion and $166.5
billion, respectively (Harwood et al., 1998). Although
no studies have estimated the annual costs of alcohol
and substance abuse among older adults, there is
evidence that the presence of drug abuse and
dependence greatly increases health care expenditures
among individuals with comorbid medical disorders.
For example, in a study of over 3 million Medicare
patients who were hospitalized and discharged with a
diagnosis of cardiovascular disease, average annual
hospital charges were $17,979 for older patients with a
concomitant diagnosis of drug dependence and $14,253
for those with a concomitant diagnosis of drug abuse.
compared with only $11,387 for older patients with no
concomitant drug disorder (Ingster & Cartwright.
1995). In addition, increased expenditures due to the
presence of a drug disorder were greatest among older
patients who also had a mental disorder.

Course
A longstanding assumption holds that substance

abuse declines as people age. Winick (1962) proposed
one of the most popular theories to explain apparent
decreases in substance abuse, particularly narcotics,
with aging. His “maturing out” theory posits that
Mental Health: A Report of the Surgeon General

factors associated with aging processes and length of
abuse contribute to a decline in the number of older
narcotic addicts. These factors include changes in
developmental stages and morbidity and mortality
associated with use of substances. Consistent with
these hypotheses, substance abusers have higher
mortality rates compared with age-matched nonabusers
(Finney & Moos, 1991; Moos et al., 1994). However,
some research contradicts the “maturing out” theory.
For example, some studies show that persons who have
been addicted for more than 5 years do not become
abstinent as they age (Haastrup & Jepsen, 1988; Hser
et al.. 1993). Also, addicts approaching 50 years of age
who were followed for more than 20 years remained
involved in criminal activitiesHser et al., 1993). These
findings emphasize the need to focus more attention on
substance abuse in late life, especially in light of
demographic trends.

Treatment of Substance Abuse and Dependence
The treatment of substance abuse and dependence in
older adults is similar to that for other adults.
Treatment involves a combination of pharmacological
and psychosocial interventions, supplemented by
family support and participation in self-help groups
(Blazer, 1996a).

Pharmacotherapy for substance abuse and
dependence in older adults has been targeted mostly at
the acute management of withdrawal. When there iS
significant physical dependence, withdrawal from
alcohol can become a life-threatening medical
emergency in older adults. The detoxification of older
adult patients ideally should be done in the inpatient
setting because of the potential medical complications
and because withdrawal symptoms in older adults can
be prolonged. Benzodiazepines are often used for
treatment of withdrawal symptoms. In older adults, the
doses required to treat the signs and symptoms of
withdrawal are usually one-half to one-third of those
required for a younger adult. Short- or intermediate-
acting forms usually are preferred.

Pharmacological agents for treatment of substance
dependence rarely have been studied in older adults.
Disulfiram use in older adults to promote abstinence is

370

not recommended because of the potential for serious
cardiovascular complications. Compounds recently
proposed for use in treatment of addiction, such as
flagyl, deserve further study. A rare controlled clinical
trial of substance abuse treatment in older patients
recently revealed naltrexone to be effective at
preventing relapse with alcohol dependence (Oslin et
al., 1997).

Service Delivery

Overview of Services

New perspectives are evolving on the nature of mental
health services for older adults and the settings in
which they are delivered. Far greater emphasis is being
placed on community-based care, which entails care
provided in homes, in outpatient settings, and through
organizations. The
community-based care has been triggered by a

community emphasis on
convergence of demographic, consumer, and public
policy imperatives. In terms of demographics,
approximately 95 percent of older persons at a given
point in time live in the community rather than in
institutions, such as nursing homes (U.S. Department of
Health and Human Services, Administration on Aging,
and American Association of Retired Persons
[U.S.DHHS, AoA & AARP], 1995). Of those living in
the community, approximately 30 percent, mostly
women. live alone (U.S. DHHS, AoA & AARP, 1995).
Most older persons prefer to remain in the community
and to maintain their independence. Yet living alone
makes them even more reliant on community-based
services if they have a mental disorder.

Service delivery also is being shaped by public
policy and the emergence of managed care. The
escalating costs of institutional care, combined with the
recognition of past abuses, stimulated policies to limit
nursing home admissions and to shift treatment to the
community (Maddox et al., 1996). Mental disorders are
leading risk factors for institutionalization (Katz &
Parmelee, 1997). Therefore, to keep older people in the
community, where they prefer to be, more energies are
being marshaled to promote mental health and to
prevent or treat mental disorders in the community. In
other words, treating mental disorders is seen as a
means to stave off costly institutionalization—resulting
either from a mental disorder or a comorbid somatic
disorder. An untreated mental disorder, for example,
can turn a minor medical problem into a life-
threatening and costly condition. Problems with
forgetting to take medication (e.g., with dementia),
developing delusions ‘about medication (e.g., with
schizophrenia), or lowering motivation to refill
prescriptions (€.g., with depression) can increase the
likelihood of having more severe illnesses that demand
more intensive and expensive institutional care.
Therefore, promotion of mental health and treatment of
mental disorders are crucial elements of service
delivery.

The delivery of community-based mental health
services for older adults faces an enormous challenge.
Services for older adults are insufficient and
fragmented, often divided between systems of health,
mental health, and social services (Gatz & Smyer,
1992; Cohen & Cairl, 1996). Under these three
systems, Services include medical and psychosocial
care, rehabilitation, recreation, housing, education, and
other supports. Yet although every community has an
Administration on Aging to assist with services for
older adults generally, there is no administrative body
responsible for integrating the daunting array of
services needed specifically for individuals with severe
mental illnesses. Similar problems are encountered
with coordinating services for children, as discussed in
Chapter 3. Local mental health authorities and systems
of care have been effective in coordinating care for
some groups of adults, but no special administrative
mental health entities exist for older adults. The
fragmentation of service systems for older people in the
United States stands in contrast to the United Kingdom
and Ireland, where governmental authorities coordinate
their care (Reifler, 1997). Older adults eventually may
benefit from the local mental health authorities
developing in the United States, but thus far these
authorities have been focused on services for other
adults. Because of ethnic diversity in the United States,
systems of care must also deal with the special needs of

371

Older Adults and Mental Health

older Americans who have limited English proficiency
and different cultural backgrounds.

The following section describes the nature and
settings in which older people receive mental health
services. It concentrates on primary care, adult day
centers and other community care settings, and nursing
homes. A recurrent theme across these settings is the
failure to address mental health needs of older people.
Selected issues in financing of services for older adults
are discussed briefly at the end of this section, but most
of the issues related to financing policy (¢.g., Medicare,

Medicaid) and managed care are discussed
Chapter 6.

in

Service Settings and the New Landscape for
Aging

Demographic, consumer, and public policy imperatives
have propelled tremendous growth in the diversity of
settings in which older persons simultaneously reside
and receive care (Table 5-2). Care is no longer the strict
province of home or nursing home. The diversity of
home settings in suburban and urban communities
extends from naturally occurring retirement
communities to continuing care retirement communities
to newer types of alternative living arrangements.
These settings include congregate or senior housing,
senior hotels, foster care, group homes, day centers
(where people reside during the day), and others. The
diversity of institutional settings includes nursing
homes, general hospitals (with and without psychiatric
units), psychiatric hospitals, and state mental hospitals,
among others. In fact, the range of settings, and the
nature of the services provided within each, has blurred
the distinction between home and nursing home (Kane,
1995).

Across the range of settings, the duration of care
can be short term or long term, depending on patients’
needs. The phrase, “long-term care,” has come to refer
to a range of services for people with chronic or
degenerative illness or disabilities who require support
over a prolonged period of time. In the past, long-term
care was synonymous with nursing home care or other

forms of institutional care, but the term has come to
Mental Health: A Report of the Surgeon General

Table 5-2. Settings for mental health services for older
adults”

 

Communities Institutions

Homes Nursing homes

Group homes General hospitals with
psychiatric units
Retirement communities
General hospitals without
Primary care and general — psychiatric units
medical sector
State mental hospitals
Outpatient therapy
Veterans Affairs hospitals
Community mental health
centers

 

>

 

 

 

*Two other settings (not included in this table) are board and
care homes and assisted living facilities. These are
residential facilities that serve as a bridge between
community and institutional settings and have elements of
each.

apply to a full complement of institutional or
community-based settings.

Within the continuum of services, one new
perspective—conceived as the landscape for aging—
strives to tailor the environment to the needs of the
person through a combined focus on health and
residential requirements (Cohen, 1994). Whether at
home, in a retirement community, or in a nursing home,
this health and home perspective is deemed to be
crucial to achieving high quality of life for older adults.
Over the past 30 years, improvements in the health side
of this perspective have occurred, but the home part has
lagged. The challenge to stimulate an
interdisciplinary collaboration between systems of care
and consumers.

is

One important area for an_ interdisciplinary
approach is the extent to which a given setting fosters
independent functioning versus dependent functioning,
an issue influencing mental health and quality of life.
Though certainly not a_ goal,
inadvertently foster dependency

some _ settings

rather than

372

independence. Nursing homes and hospitals, for
example, are understandably more focused on what
individuals cannot do, as opposed to what they can do.
Yet their major focus on incapacity (the nursing and
health focus) runs the risk of overshadowing function

‘and independence (the home and humanities focus). In

other settings, the balance between dependence and
independence shifts in the other direction, with the risk
of nursing and health needs being inadequately
addressed. In recent years, the emphasis has been on
“aging in place,” either at home or in the community,
rather than in alternate settings.

The landscape for aging is a construct within
which to examine the depth and breadth of human
experience in later life (Cohen, 1998b). A health and
humanities focus across this landscape offers a design
for dealing with mental health problems as well as with
health promotion to harness human potential. The
landscape for aging, with its health and humanities
orientation, is a construct designed to stir new thinking
in research, practice, and policy. It also defines a clear
need for new mental health services’ development and
delivery, training, research, and policies to address the
range of sites, each with its own unique characteristics
and growing populations. The service systems,
however, have yet to embrace a broader view.

Primary Care

Primary care® represents a pivotal setting for the
identification and treatment of mental disorders in older
people. Many older people prefer to receive mental
health treatment in primary care (Unutzer et al., 1997a),
a preference bolstered by public financing policies that
encourage their increasing reliance on primary, rather
than specialty, mental health care (Mechanic, 1998).
Primary care offers the potential advantages of
proximity, affordability, convenience, and coordination
of care for mental and somatic disorders, given that
comorbidity is typical.

 

® Primary care includes services provided by general practitioners,
family physicians, general internists, certain specialists designated
as primary care physicians (such as pediatricians and obstetrician-
gynecologists), nurse practitioners, physician assistants, and other
health care professionals. General medical settings include all
primary care settings plus all non-mental health specialty care.
The potential advantages of primary care, however,
have yet to be realized. Diagnosis and treatment of
older people’s mental disorders in the primary care
setting are inadequate. The efficacious treatments
described in the depression section of this chapter are
not being practiced, particularly not in primary care and
other general medical settings. As documented earlier,
a significant percentage of older patients with
depression are underdiagnosed and undertreated. The
concern about inadequate treatment of late-life
depression in primary care is magnified by growing
enrollment in managed care.

Primary care is generally not well equipped to treat
chronic mental disorders such as depression or
dementia. It has limited capacity to identify patients
with common mental disorders and to provide the
proactive followup that is required to retain patients in
treatment. To ensure better treatment of late-life
depression in primary care, there is heightening
awareness of the need for new models for mental health
service delivery (Unutzer et al., 1997a). New models of
service delivery in primary care include mental health
teams, consultation-liaison models,’ and integration of
mental health professionals into primary care (Katon &
Gonzales, 1994; Schulberg et al., 1995; Katon et al.,
1996, 1997; Stolee et al., 1996; Gask et al., 1997). For
example, the intervention developed by Katon and
colleagues introduced a structured depression treatment
program into the primary care setting. The program
included behavioral treatment to inculcate more
adaptive coping strategies and counseling to enhance
compliance with antidepressant medications. Patients
were randomized in a controlled trial comparing this
structured depression program with usual care by
primary care physicians. The investigators found
patients participating in the program to have displayed
better medication adherence, better satisfaction with
care, and a greater decrease in severity of major
depression (Katon et al., 1996).

 

7 Consultation-liaison models provide a bridge between psychiatry
and the rest of medicine. In most models, a mental health specialist
is called in as a consultant at the request of a primary care provider
or works as a regular member of a team of health care providers.

373

Older Adults and Mental Health

Models that integrate mental health treatment into
primary care, while thus far designed largely for
depression, also may have utility for other mental
disorders seen in primary care. Nevertheless, primary
care is not appropriate for all patients with mental
disorders. Primary care providers can be guided by a
set of recommendations for appropriate referrals to
specialty mental health care (American Association for
Geriatric Psychiatry, 1997).

Adult Day Centers and Other Community Care
Settings

Over the past few decades, adult day centers have
developed as an important service delivery approach to
providing community-based long-term care. Adult day
centers, although heterogeneous in orientation, provide
a range of services (usually during standard “9 to 5”
business hours), including assessment, social, and
recreation services, for adults with chronic and serious
disabilities. They represent a form of respite care
designed to give caregivers a break from the
responsibility of providing care and to enable them to
pursue employment. Over the past 30 years, adult day
centers have grown in number from fewer than 100 to
over 4,000, under the sponsorship of community
organizations or residential facilities. A large national
demonstration program on adult day centers showed
that they can care for a wide spectrum of patients with
Alzheimer’s disease and related dementias and can
achieve financial viability (Reifler et al., 1997; Reifler
et al., in press). There also is evidence that adult day
centers are cost-effective in terms of delaying
institutionalization, and participants show improvement
in some measures of functioning and mood (Wimo et
al., 1993, 1994).

There are several approaches to delivering services
in adult day centers. There is no research evidence that
any one model of service delivery is superior to
another. For example, a social model has been
developed by Little Havana Activities & Nutrition
Centers of Dade County (Florida). The Little Havana
Senior Center provides mental health, health, social,
nutritional, transportation, and recreational services,
emphasizing both remedial and preventive services.
Mental Health: A Report of the Surgeon General

The center focuses on the predominantly Cuban
population of South Florida. Yet much more research
is needed to demonstrate the relative effectiveness of
different models of adult day services (Reifler et al.,
1997).

Beyond adult day centers, other innovative models
of community-based ‘long-term care strive to
incorporate mental health services. Few have been
evaluated and none implemented on a wide scale.
These models include the social/health maintenance
organization (S/HMO) (Greenberg et al., 1988), On
Lok Senior and
communities continuing care retirement
communities (Robinson, 1990b). These new features of
the landscape of aging show promise, but there is
insufficient

Services Program, life care

or

of cost-effectiveness and
generalizability of these models, particularly the mental
health component. Perhaps the lack of a research base
and limited market account for the slow pace of their
proliferation in the United States.

evidence

Nursing Homes

Most older adults live in the community and only a
minority of them live in nursing homes; of the latter,
about two-thirds have some kind of mental disorder
(Burns, 1991). The majority have some type of
dementia, while others have disabling depression or
schizophrenia (Burns, 1991). Despite the high
prevalence of people with mental disorders in nursing
homes, these settings generally are ill equipped to meet
their needs (Lombardo, 1994).

Deinstitutionalization of state mental hospitals
beginning in the 1960s encouraged the expanded use of
nursing homes for older adults with mental disorders.
This trend was enhanced by Medicaid incentives to use
nursing homes instead of mental hospitals. But the shift
to nursing homes was not accompanied by alterations
in care. In 1986, the Institute of Medicine issued a
landmark report documenting inappropriate and
inadequate care in nursing homes, including the
excessive use of physical and chemical restraints (IOM,
1986). This subsequent visibility of problems prompted
the passage in 1987 of the Nursing Home Reform Act
(also known as the Omnibus Budget Reconciliation Act

374

of 1987). This legislation restricted the inappropriate
use of restraints and required preadmission screening
for all persons suspected of having serious mental
illness. The purpose of the screening was to exclude
from nursing homes people with mental disorders who
needed either more appropriate acute treatment in
hospitals or long-term treatment in community-based
settings. Preadmission screening also was designed to
improve the quality of psychosocial assessments and
care for nursing home residents with mental disorders.
Nursing home placement is appropriate for patients
with mental disorders if the disorders have produced
such significant dysfunction that patients are unable to
perform activities of daily living.

To meet the legislation’s requirements, nursing
homes must have the capacity to deliver mental health
care. Such capacity depends on trained mental health
professionals to deliver appropriate care and treatment.
Unfortunately, prior to and even after passage of the
Omnibus Budget Reconciliation Act of 1987, Medicaid
policies discouraged nursing homes from providing
specialized mental health services, and Medicaid
reimbursements for nursing home patients have been
too low to provide a strong incentive for participation
by highly trained mental health providers (Taube et al.
1990). The emphasis on community-based care,
combined with inadequate nursing home
reimbursement policies, has limited the development of
innovative mental health services in nursing homes.
Major barriers persist in the delivery of appropriate
care to mentally ill residents of nursing homes.

Services for Persons With Severe and Persistent
Mental Disorders

Older adults with severe and persistent mental
disorders (SPMD) are the most frequent users of long-
term care either in community or institutional settings.
SPMD in older adults includes lifelong and late-onset
schizophrenia, delusional disorder, bipolar disorder,
and recurrent major depression. It also includes
Alzheimer’s disease and other dementias (and related
behavioral symptoms, including psychosis), severe
treatment-refractory depression, or severe behavioral
problems requiring intensive and prolonged psychiatric
intervention. Although these groups of disorders have
different courses of illness and outcomes, they have
many overlapping clinical features, share the common
need for mental health long-term care services, and are
frequently treated together in long-term care settings
(Burns, 1991; Gottesman et al., 1991; American
Psychiatric Association, 1993). It is estimated that 0.8
percent of persons older than 55 years in the United
States have SPMD (Kessler et al., 1996).

As aresult of the dramatic downsizing and closure
of state hospitals in past decades, 89 percent of
institutionalized older persons with SPMD now live in
nursing homes (Burns, 1991). However, institutions are
expected to play a substantially smaller role than
community-based settings in future systems of mental
health long-term care (Bartéls et al., in press). First, the
majority of older adults with SPMD presently live in
the community (Meeks & Murrell, 1997; Meeks et al.,
1997) and prefer to remain there. Second, experience
with the Preadmission Screening and Resident Review
mandated by the Omnibus Budget Reconciliation Act
of 1987 has been mixed. It may have slowed
inappropriate admissions to nursing homes, restricted
inappropriate use of restraints, and reduced overuse of
psychotropic medications, but it did not .otherwise
improve the quality of mental health services
(Lombardo, 1994). Furthermore, states’ opposition to
what they perceived to be Federal government
interference in local health care policy and a general
trend toward deregulation subsequently curtailed
Federal nursing home reform. Finally, the growing
costs of nursing home care are stimulating dramatic
reforms in reimbursement and policy, including state
mandates to limit Medicaid expenditures by decreasing
nursing home beds and Federal reform by Medicare to
implement prospective payment for nursing home
services (Bartels & Levine, 1998). To accommodate the
mounting number of individuals who have disorders
requiring chronic care, future projections suggest the
greatest growth in services will be in home and
community-based settings (Institute for Health and
Aging, 1996), increasingly financed through capitated
and managed care arrangements.

375

Older Adults and Mental Health

Older adults with SPMD are high users of services
(Cuffel et al., 1996; Semke & Jensen, 1997) and require
mental health long-term care that is comprehensive,
integrated, and multidisciplinary (Moak, 1996; Small et
al., 1997: Bartels & Colenda, 1998). The mental health
care needs of this population include specialized
geropsychiatric services (Moak, 1996); integrated
medical care (Moak & Fisher, 1991; Small et al.
1997); dementia care (Small et al., 1997; Bartels &
Colenda, 1998); home and community-based long-term
care; and residential and family support services,
intensive case management, and psychosocial
rehabilitation services (Aiken, 1990; Robinson, 1990a;
Schaftt & Randolph, 1994; Lipsman, 1996). With
adequate supports, older persons with SPMD can be
maintained in the community, sometimes at lower cost,
and with equal or improved quality of life in
comparison with institutions (Bernstein & Hensley,
1988; Mosher-Ashley, 1989; Leff, 1993; Trieman etal.,
1996).

However, current mental health policies have left
many older persons with SPMD with decreased access
to mental health care in both community and
institutional settings (Knight et al., 1998). Community-
based mental health services for older people are
largely provided through the general medical sector,
partly due to poor responsiveness to the needs of older
people by community mental health organizations
(Light et al., 1986). Yet reliance on the general medical
sector also has not met their needs because of its focus
on acute care (George, 1992). In addition, most home
health agencies provide only limited short-term mental
health care. The long-term care programs that exist
primarily aid older adults with chronic physical
disabilities or cognitive impairment but fail to address
impairments in mood and behavior (Robinson, 1990a).
An additional barrier is that the majority of
community-residing older adults do not seek mental
health services, except for medication (Meeks &
Murrell, 1997), despite continued need (Meeks et al.,
1997). Those without family support generally live in
nursing homes, assisted living facilities, and board and
care homes. These three are forms of residential care
that offer some combination of housing, supportive