Zvi D. Gellis, PhD, University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
Introduction
Interest in evidence-based geriatric mental health knowledge and effective practice interventions has never been greater. The purpose of the following literature reviews in mental health is to provide needed information to a diverse social work audience including faculty, students, and practitioners who teach, do research or work in the mental health field. Upon examination of the empirical literature, we found gaps in the current knowledge on effective mental health interventions or limitations on generalizability to diverse settings: for example, home health care, naturally occurring retirement communities, home visiting and faith communities, meals-on-wheels, senior centers, older ethnic minorities, racial/health disparities, older GLBT population, and community-based geriatric mental health settings to name a few. Where empirical content is available, data have been included in the literature reviews.
As the population of the United States ages, a growing number of older adults will have mental health problems ranging from mild or subthreshold conditions such as minor depression and subthreshold anxiety, to severe and persistent mental illnesses, such as severe and recurrent major depression and schizophrenia, all known to reduce quality of life.
Current estimates of mental illness rates in older adults range from 15 to 25%, and the number of older adults with a serious mental illness is expected to climb from about 4 million in 1970 to nearly 15 million by 2030 (Administration on Aging, 2002). In addition to mental disorders common in all age groups, there are cognitive problems that, while not unique to older adults, occur with increasing frequency with age. These cognitive impairments exist on a continuum from normal age-associated memory decline (AAMD) to mild cognitive impairment (MCI) to dementias, such as Alzheimer’s disease and vascular dementias. These mental illnesses are further complicated by frequent comorbidity with medical problems, substance use problems, and social problems such as loss of loved ones and changes in living situation.
Taken together, mental illnesses among older adults constitute a major and growing public health problem. This increase in the number of older adults with mental health problems is expected to far exceed the capacity of the mental health system to deliver needed services resulting in large numbers of individuals with unmet mental health needs. Even now it is estimated that less than a quarter of older adults with mental health needs ever receive treatment—a problem that exists across a range of service settings from community/outpatient settings to hospital settings to residential and long-term care facilities (Kaskie & Estes, 2001). One estimate places this number as low as 2.5% receiving care from traditional mental health services and another 2% receiving mental health assistance from their primary care physician (Blazer, 2002).
Part of the failure to provide adequate mental health services is due to the fact that many older adults are reluctant to seek such services or to spontaneously report mental health problems because of various barriers such as potential costs, transportation, stigma, denial of problems, service access barriers, language barriers, or a lack of culturally appropriate professionals and programs. Older adults may not receive adequate mental health care, even when a problem is identified, because of fragmented mental health services or to gaps in mental health services. Finally there is a serious shortage of professional staff with adequate training to meet the mental health needs of older adults and their caregivers (Gellis, 2006).
Given the fact that older adults are living in the community for more years than they were in past, it is increasingly likely that mental health care will be provided in community settings, many of which are non-specialty, general mental health programs. Social workers have a key role in providing therapy and case management to older adults and their caregivers and in delivering psychoeducation and prevention services to the community. Most mental health practitioners, including social workers, who are not participating in specialty geriatric concentrations are provided with little exposure to practice with older adults, either in their classes or in their field internships, yet they are likely to be called upon to provide services to older adults after they graduate (Rosen, 2005).
In the series of literature reviews, we summarize the evidence (based on the existing scientific literature) on the prevalence, course, co-morbidity, assessment, and effectiveness of a range of empirically-supported treatments (pharmacological and psychosocial) for depression disorders, anxiety disorders, schizophrenia, and the co-occurrence of depression and dementia in older adults. “Evidence-based” refers here to a process rather than an intervention. “Effectiveness” refers here to an improvement in health or mental health outcomes produced by a clearly delineated intervention. The aim of these reviews is to promote greater attention to mental health issues in old age in social work curricula.
Our searches were conducted on the following databases: PubMed (1997-2007/December); PsycInfo (1972-2007); Ageline (1978-2007); and EbscoHost Research—Academic Search Premier (through 2007). In addition, we looked up citations from articles located in the electronic searches. Google Scholar was also searched using the parameter of November 2007 through February 2008 to identify recent publications that would not have been otherwise cited. Unpublished literature was not included in the review. For computer searches we used the following terms: aged, elder*, old*, late life, geri*, long term care, dementia, Alzheimer*, depress*, mood disorder, anxiety, schizophrenia, assessment, treatment, intervention, and randomized controlled trials.
Our reviews include studies of adults 65 years or older. For the majority of the reviews, the population discussed includes community-dwelling noninstitutionalized older adults except for the review on dementia. Our initial strategy was to first examine systematic review articles to locate relevant studies; second we looked at meta-analyses; third we appraised other reviews of the literature; fourth we assessed randomized controlled trials (RCTs), or if these were unavailable, other types of studies reported in English language peer-reviewed journals. Articles were included only if they reported on the assessment and treatment of older adults with either depression, anxiety, schizophrenia, or depression in dementia. The reviewed studies in geriatric mental health were generally evaluated using the Agency for Health Research Quality (AHRQ) system for levels of evidence in research quality:
- LEVEL A: randomized controlled clinical trials.
- LEVEL B: well designed clinical studies without randomization or placebo comparisons.
- LEVEL C: service and naturalistic clinical studies, combined with clinical observations, which are sufficiently compelling to warrant use of the treatment technique or follow the specific recommendations.
- LEVEL D: long-standing and wide-spread clinical practice that has not been subjected to empirical tests.
- LEVEL E: long-standing practice by circumscribed groups of clinicians that has not been subjected to empirical tests.
- LEVEL F: recently developed treatment that has not been subjected to clinical or empirical tests.
The main emphasis of the reviews was on RCTs (Level A). These levels of evidence do not directly describe the quality or credibility of the evidence. Rather, they indicate the nature of the evidence being used. In general, an RCT has the strongest credibility (Level A); yet, it may have weaknesses that diminish its value (Level B), and these should be noted. In general, Level C studies carry less credibility than level A or B studies, but credibility is increased when consistent results are obtained from several level C studies carried out at different times and in different places. Decisions must often be made in the absence of published empirical evidence. In such circumstances it is imperative to use expert opinion based on knowledge and clinical experience (designated as evidence Level E).
This Mental Health and Aging Resource Review is designed to be a resource and to provide links to other resources for faculty teaching the advanced mental health practice curriculum in master’s level social work programs. The specific topics included in this module were selected because of their prevalence among older adults, the distinctive challenges they present to diagnose and to treat in older adults, their impact on caregivers and service providers, and the existence of controversies about the nature of the conditions and even their presence in older adults. Both anxiety disorders and mood disorders are quite prevalent among older adults, as are depressive disorders and generalized anxiety disorder. Social workers in any setting that serves older adults need to be able to screen for, evaluate, and provide treatment for these problems. Anxiety, depression, and psychotic symptoms all provide diagnostic and treatment challenges for several reasons:
- Older Adult Reluctance: Older adults are reluctant to mention relevant symptoms to health care providers. They may lack insight into the presence of the symptoms, which often happens in the case of psychotic symptoms; they may be concerned about stigma associated with mental illness; they may feel that the symptoms are just a normal part of aging; or they may believe that the symptoms are of physical rather than psychological in origin, e.g., related to a medical illness or fatigue.
- Diagnostic Issues: These kinds of symptoms may be associated with a variety of general medical conditions and a number of medications, including alcohol and other non-medical drugs. For example, it is difficult to distinguish the apathy of an individual with dementia from depression or negative symptoms of schizophrenia.
- Pharmacological Treatment Issues: These problems can be complicated to treat with medication because of concerns about drug interactions and side effects. Additionally, older adults do not metabolize drugs as efficiently as younger individuals and thus may need lower doses of medication. At the same time, a common reason for lack of response to antidepressant medication is failure to prescribe an adequate dose of antidepressant.
- Nonpharmacological Treatment Issues: There is a paucity of research on the response of older adults to nonpharmacological treatment. Although there has been research on interventions like problem solving therapy, cognitive behavioral therapy, and interpersonal therapy, few studies have compared the efficacy of different approaches, and almost no studies have examined interventions among older minority adults.
Each section in this Mental Health Resource Review contains a chapter that functions as an annotated outline of lecture notes with teaching and practice resources, selected readings, and a case study exercise; Power Point slides that follow the lecture notes; and a narrative literature review of the research upon which the lecture notes were based. The slides and lecture notes can be used in their entirety as a stand-alone presentation on the topic, or specific slides can be copied and pasted to add aging content to existing presentations in a particular area. In fact, adding to existing lectures and presentations is the way that this material will presumably most often be used. For this reason, we did not include background material, such as DSM criteria for the disorders, detailed explanations of the mechanism of action of medications, or discussions of the basic methods of different therapeutic approaches. The final chapter outlines next steps in the study of older adults with mental illnesses, followed by an appendix providing a separate list compiling all the resources mentioned in the individual chapters. We hope this module will provide user-friendly resources for non-gerontology faculty who recognize the importance of adding aging content to their mental health courses, as well as, perhaps a few resources and ideas for faculty specializing in geriatric mental health.
References
Administration on Aging. (2002). A profile of older Americans. Washington, DC: Department of Health and Human Services.
Blazer, D. (2002). Depression in later life. (3rd ed.). New York: Springer Publishing.
Kaskie, B., & Estes, C. L. (2001). Mental health services policy and the aging. Journal of Gerontological Social Work, 36(3/4), 99-114.
Gellis, Z. D. (2006). Mental health and emotional disorders among older adults. In
B. Berkman (Ed.), Oxford Handbook of Social Work in Health and Aging (pp. 129-139). New York: Oxford University Press.
Rosen, A. (2005). The Shortage of an Adequately Trained Geriatric Mental Health Workforce. Testimony to the Policy Committee of the
White House Conference on Aging. Retrieved February 18, 2006, from http://www.whcoa.gov/about/policy/meetings/Jan_24/Rosen WHCOA testimony.pdf
Document Date: September 9, 2009
Zvi D. Gellis, PhD, University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
Master's Advanced Curriculum (MAC) Project Mental Health and Aging Resource Review 2014 Revision
Significance
- Anxiety Disorders often are associated with common age-related medical and psychosocial problems.
Epidemiological evidence suggests that anxiety is a common and major problem in later life, yet it has received less attention than depressive disorders have. Anxiety disorders are often associated with common age-related medical and chronic conditions such as asthma, thyroid disease, coronary artery disease, dementia, and sensory loss (Diala & Muntaner, 2003).
- Late life anxiety is a risk factor for greater disability in general, less successful recruitment and engagement in rehabilitation services.
Anxiety in later life has been identified as a risk factor for greater disability among older adults in general and has also been associated with less successful recruitment into and outcomes of geriatric rehabilitation services (Bowling, Farquhart, & Grundy, 1996). Researchers and practitioners are beginning to recognize that aging and anxiety are not mutually exclusive; anxiety is as common in the old as in the young, although how and when it appears is distinctly different in older adults. Additionally, further effectiveness research on evidence-based treatments for late life anxiety is needed (Mitte, 2005).
- Diagnostic Difficulties
- Medical conditions: It is difficult to separate physical symptoms of anxiety disorders from medical conditions due to higher prevalence of certain medical conditions, realistic concerns about physical problems, and higher use of prescription medications.
- Dementia: It is difficult to separate agitation from anxiety; impaired memory may relate to anxiety or dementia; fear may be excessive or realistic depending upon the situation.
- Depression: In late-life, anxiety may be more likely to include depressive symptoms.
Recognizing anxiety and anxiety disorders in an older person poses several challenges. Aging brings with it an increased risk for certain medical conditions; a number of realistic concerns about physical problems, life situations, and functioning; and a high use of prescription medications. As a result, separating a medical condition from physical symptoms of an anxiety disorder is complicated in the older adult. Diagnosing anxiety in individuals with dementia can be difficult, too: agitation typical of dementia may be difficult to separate from anxiety, impaired memory may be interpreted as a sign of anxiety or dementia, and fears may be excessive or realistic depending on the person's situation.
Epidemiology of Anxiety Disorders
- Anxiety disorders are the most common class of psychiatric disorders in older adults—more common than either depression or severe cognitive impairment.
Although anxiety disorders, like most psychiatric conditions, may be less common among older adults than among younger people, epidemiological evidence suggests that anxiety is a major problem in late life (Salzman & Lebowitz, 1991; U.S. Department of Health & Human Services, 1999). Anxiety disorders overall appear to be the most common class of psychiatric disorders among older people, more prevalent than depression or severe cognitive impairment (Beekman et al., 1998; Kessler et al., 2005; Regier et al., 1988).
- 10 to 15% of people 65+ are coping with at least one anxiety disorder.
One study involving interviews with nearly 6000 people nationwide reported a lifetime rate of 15.3% for DSM-IV-diagnosed anxiety disorders in respondents over age 60 (Kessler et al., 2005). Myers and colleagues (1984) report a 6-month prevalence of anxiety disorders in late life ranging from 6.6% to 14.9% across three Epidemiologic Catchment Area (ECA) sites.
- Most common anxiety disorders among older adults are Generalized Anxiety Disorders (GADs).
Phobias and GADs account for most anxiety disorders in late life (Beekman, van Balkom, Deeg, van Dyck, & van Tilburg, 2000; LeRoux, Gatz, & Wetherell, 2005). Among people 55 years of age and older, Douchet, LaDouceur, Freeston, and Dugas (1998) found that 12.8% meet criteria for GAD. By comparison, ECA prevalence rates for older adults are 1.8% for major depression, 2.8% for dysthymia, and 4.9% for severe cognitive impairment (Blazer, 1997; Regier et al., 1988).
- Prevalence of anxiety may be higher in Primary Care settings than in the community.
- 30% of older adults present with GAD symptoms.
- Since only about one third of anxiety disorder cases is detected in primary care settings, estimates likely substantially underestimate the true prevalence.
It is possible that the prevalence of anxiety is higher in primary care settings than in the community at large. Krasucki, Howard, and Mann (1999) have found that, in primary care settings, 30% of older adults present with generalized anxiety symptoms. Because evidence suggests that only approximately one third of such cases are detected in primary care (e.g., Kessler, Lloyd, Lewis, & Gray, 1999), these data likely represent a substantial underestimate of the prevalence of anxiety in that setting. Furthermore, Levy, Conway, Brommelhoff, and Merikengas (2003) found that, compared to younger adults, older adults tend to minimize and underreport their anxiety symptoms. Thus the number of older adults who experience anxiety may be underestimated (Levy et al., 2003).
- Subthreshold Anxiety Symptoms: Clinically significant anxiety, including symptoms that do not meet criteria for a specific disorder, is common among older adults (20-29%).
Clinically significant anxiety, including symptoms that do not meet criteria for a specific disorder, is common among older adults, and the prevalence may be as high as 20-29% (Davis, Moye, & Karel, 2002; Lenze et al., 2005).
- Many of the symptoms of anxiety are physical and overlap with medical problems; conversely, anxiety is often associated with common age-related medical and chronic conditions such as asthma, thyroid disease, coronary artery disease, dementia, and sensory loss. It is also associated with stressors, such as bereavement and care-giving.
There is also controversy over whether the prevalence of anxiety has been accurately determined in older adults, because DSM-IV criteria may not fit well with this population, anxiety symptoms may be expressed as somatic features or behavior changes (e.g., aggression, assaultive behaviors), and the clinical presentation of anxiety in late life may be more likely to include depressive symptoms (Beck & Averill, 2004; Diefenbach & Goethe, 2006; Fuentes & Cox, 1997; Kim, Braun, & Kunik, 2001; Palmer, Jeste, & Sheikh, 1997).
Comorbidity Issues: Medical
- High comorbidity of anxiety with medical illness is multidimensional.
- Anxiety may be a reaction to medical illness.
- Anxiety may be expressed as somatic symptoms.
- Anxiety may be a reaction to medications.
- Anxiety may impact medical care—prevent seeking or following through with care, provoke excessive help-seeking behavior.
- Anxiety is associated with markedly higher health care costs (even after adjusting for medical comorbidity).
- Studies have found an association between anxiety and medical illnesses, such as diabetes, coronary heart disease, cancer, chronic obstructive pulmonary disease, gastrointestinal disorders, Parkinson’s disease, and dementia.
Studies have found an association between anxiety and medical illnesses such as diabetes (Blazer, 2003), dementia (Wrag & Jeste, 1989), coronary heart disease (Artero, Astruc, Courtet, & Ritchie, 2006; Kuzbansky, Cole, Kawachi, Vokonas, & Sparrow, 2006), cancer (Deimling, Bowman, Sterns, Wagner, & Kahana, 2006; Ostir & Goodwin, 2006), chronic obstructive pulmonary disease (Karajgi, Rifkin, Doddi, & Kolli, 1990), and Parkinson’s disease (Stein, Heuser, Juncos, & Uhde, 1990).
Comorbidity Issue: Depression
- Anxiety in older adults often co-occurs with depression.
- Twenty-five percent of older adults with anxiety also have major depression; up to 50% of older adults with major depression have comorbid anxiety disorder; and approximately 20% of older adults with bipolar disorder report having had GAD at some point in their life.
As with young adults, anxiety in older adults has been found to often co-occur with depression (Beck & Averill, 2004; Beekman et al., 1998; Blazer, 1997). Community survey research has revealed that up to 50% of older adults with major depression had a comorbid anxiety disorder, and 25% of older adults with anxiety also had major depression (Beekman et al., 2000; Blazer, 2003; Jeste, Hays, & Steffens, 2006). Finally, approximately 20% of older adults with bipolar disorder reported having GAD at some point (Goldstein, Hermann, & Shulman, 2006).
- There is an increased risk for poor outcome in cases of comorbid anxiety and depression: poor treatment response and increased dropout, increased suicidality, and reduced psychosocial support.
Comorbid anxiety in late-life depression is associated with poor treatment response and increased likelihood of dropout (Lenze et al., 2003). Also, older people with anxious depression report increased suicidality and reduced psychosocial supports (Jeste et al., 2006).
- Sequence of anxiety and depression.
- Anxiety far more commonly precedes depression than vice versa.
- Some episodes of depression may begin with anxiety symptoms.
Anxiety symptoms have been found to lead to depressive symptoms (Wetherell, Gatz, & Pederson, 2001).
Consequences of Anxiety
- Medical consequences.
- Hypertension, hypoglycemia, and coronary heart disease can be worsened through chronic stress and anxiety.
- Men reporting > 2 anxiety symptoms had elevated risk of fatal coronary disease.
- Anxiety is related to pain in nursing home residents.
- High levels of anxiety are related to increased use of pain medications and more disability post-surgery.
Hypertension, hypoglycemia, and coronary heart disease can be worsened through chronic stress and anxiety (Hersen & Van Hasselt, 1992). Compared with men reporting no symptoms of anxiety, men in the Normative Aging Study reporting two or more anxiety symptoms had elevated risk of fatal coronary heart disease (Kawachi, Sparrow, Vokonas, & Weiss, 1994). Higher levels of anxiety have been associated with greater use of pain-relieving medications and more postoperative disability days for surgical patients (Taenzer, Melzack, & Jeans, 1986). Anxiety was also related to pain in a sample of nursing home residents (Casten, Parmelee, Kleban, Lawton, & Katz, 1995).
- Well-being and Quality of Life (QOL).
- Anxiety symptoms and disorders are associated with increased fatigue, increased disability, more chronic physical illness, lower levels of well-being, worse life satisfaction, and inappropriate use of medical services.
- Older adults with GAD reported QOL impairments comparable to those of persons with major depression and greater than those of persons with serious medical conditions like myocardial infarction and Type II diabetes (Non-Insulin Dependent Diabetes Melitis, NIDDM).
Among older adults, anxiety symptoms and disorders are associated with increased fatigue, high levels of chronic physical illness, increased disability, lower levels of well-being, substandard life satisfaction, and inappropriate use of medical services (Gellis, 2006).
(Martin, Bishop, Poon, & Johnson, 2006; Brenes et al., 2005; de Beurs, et al., 1999; Hunt, Issakidis, & Andrews, 2002; Jones, Ames, Jeffries, Scarinci, & Brantley, 2001; Wetherell et al., 2004; Wittchen, Carter, Pfister, Montgomery, & Kessler, 2000). Furthermore, a sample of older adults with GAD reported impairments on QOL measures that were worse than impairments reported by comparable individuals who had serious medical conditions such as myocardial infarction or type II diabetes and comparable to individuals with major depression (Wetherell et al., 2004).
What do Older Adults Say When Asked About Anxiety?
- “I worry so much, I can’t control it.”
- “A feeling of fear comes over me, and I get short of breath. My heart pounds, and I think that I’m going to die.”
- “I feel very nervous around other people, and I try to avoid having any attention called to me.”
- “I can’t get these thoughts out of my head, and they make me very anxious.”
- “Ever since the accident, I can’t stop thinking about it.”
Identifying, Screening, Assessing, and Diagnosing Anxiety Disorders in Older Adults
- Presentation of Anxiety Disorders in older adults.
- Anxiety symptoms can be part of a reaction to illness, declined functioning, or care-giving.
- Anxiety may be expressed solely in terms of somatic symptoms that have no medical cause.
- Older adults may complain of headaches, chest pains, fatigue, stomach pains, etc.
- Gap between Prevalence and Treatment.
- Older adults with anxiety are less likely to receive treatment from a mental health specialist that those with depression, dementia, or any other mental disorder.
- Older adults tend to minimize and underreport their anxiety symptoms.
Older adults with anxiety disorders are less likely than older adults with depression, dementia, or any other mental disorder to receive treatment from a mental health specialist (Ettner & Hermann, 1997). Levy et al. (2003) found that, compared to younger adults, older adults tend to minimize and underreport their anxiety symptoms.
- Detection precedes treatment.
- Detection rates are poor due to:
- Reluctance of elderly to seek care.
- Lack of knowledge and/or reluctance of Human Services/primary care physicians to detect or refer.
- Disguised presentation of anxiety related to medical conditions.
- Anxiety becomes constructed as an emotional problem:
- If it is experienced with great frequency and intensity.
- If it interferes with psychosocial functioning.
- If it occurs when there is no threat.
- To help identify anxiety it may be useful to phrase questions in the following way.
- To identify anxiety:
- Have you been concerned about or fretted over a number of things?
- Is there anything going on in your life that is causing you concern?
- Do you find that you have a hard time putting things out of your mind?
- To identify how and when physical symptoms began:
- What were you doing when you noticed the chest pain?
- What were you thinking about when you felt your heart start to race?
- When you can't sleep, what is usually going through your head?
- Adapted from Lang, A. J., and Stein, M. B., (2001). Geriatrics, 56(5), 24-27, 31-34.
Treatment of Anxiety Disorders in Older Adults
Pharmacological Treatment
- In part due to the tendency for older adults to present to primary care physicians for treatment of anxiety symptoms, anxiolytic medications, including benzodiazepines, are most common treatments for late life anxiety.
- Pharmacological interventions must be used cautiously in older adults: older adults experience changes in metabolism that influence dose range and side effects, risk of interactions with other drugs, and effects of medication on comorbid medical problems.
- Benzodiazepines:
- Higher use in older than in younger adults: a community survey in California found 20% of older adults had used benzodiazepines > 2 times in past year.
- Benzodiazepines have a calming effect, produce sedation, promote sleep, and have some muscle relaxant and anticonvulsive effects.
- Short-term use with minimal therapeutic doses is recommended.
- Onset of the effects of these drugs is rapid; therefore, they are used for symptomatic relief of acute anxiety.
- Disadvantages:
- They can become addictive; withdrawal symptoms, which mimic symptoms of anxiety, can occur upon cessation of use; potential for drug interactions particularly with sedating drugs, such as alcohol; due to changes in metabolism benzodiazepines take longer to clear from bloodstream of older adults and can build up leading to toxicity.
- Side effects:
- Fatigue, sedation, amnesia, and slurred speech and ataxia (staggering) at high dosages.
- Risks associated with use:
- Users more likely than non-users to experience accidents requiring medical attention due to increased risk of falls, hip fractures, and auto accidents.
- Older adults taking benzodiazepines more likely to develop disabilities in both mobility and activities of daily living (ADLs).
- Impairment of memory and other cognitive functions.
Data from the ECA study suggest that benzodiazepine use among the elderly is approximately 14%, higher than the rate for younger adults (Swartz et al., 1991). A community survey of older adults in southern California showed that 20% had used benzodiazepines at least twice in the previous 12 months; these individuals were more than twice as likely as nonusers to take 10 or more drugs (Mayer-Oakes et al., 1993). Benzodiazepine users are also more likely than nonusers to experience accidents requiring medical attention, due to increased risk of falls, hip fractures, and automobile accidents (Tamblyn, Abrahamowicz, du Berger, McLeod, & Bartlett, G, 2005). Older patients taking benzodiazepines are also more likely to develop disabilities in both mobility and ADLs (Gray et al., 2006). Benzodiazepines can impair memory and other cognitive functions (Wengel, Burke, Ranno, & Roccaforte, 1993). These medications can also cause tolerance and withdrawal, interactions with other drugs, and toxicity (Krasucki et al., 1999; Salzman & Lebowitz, 1991).
- Selective serotonin reuptake inhibitors (SSRIs).
- Serotonin selective reuptake inhibitors (SSRIs) may be relatively safe in older adults and are more effective for many anxiety disorders (e.g., PTSD, OCD).
- They can cause unpleasant side effects and some older adults prefer not to take them.
- Nausea, diarrhea, nervousness, and insomnia are the most frequently reported adverse effects of SSRIs. Headache, tremor, anxiety, somnolence, and sexual dysfunction are also reported.
Although safer medications than benzodiazepines, particularly SSRIs, are often used to treat geriatric anxiety, they can cause unpleasant side effects, and some older people prefer not to take them. Furthermore, SSRIs have not completely replaced benzodiazepines as a treatment for anxiety in older people (Keene, Eaddy, Nelson, & Sarnes, 2005).
- Other Medications.
- Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are effective in treating anxiety disorders. They have been used less frequently since the development of newer antidepressants, such as SSRIs.
- TCAs are associated with unpleasant side effects, toxicity, and the potential for adverse cardiac effects, particularly when used in older adults.
- MAOIs are associated with very serious interactions with other drugs and need to avoid foods with tyramine.
Both monoamine oxidase inhibitors and tricyclic antidepressants have been demonstrated to be effective in treating anxiety disorders, such as panic disorder and obsessive compulsive disorder. Due to the discomfort and dangerousness of their side effect profile, they currently are used less frequently than newer medications such as SSRI’s (Kelsey, Newport, & Nemeroff, 2006).
Psychosocial Treatments
- Several studies have provided support for the use of relaxation training, cognitive behavioral therapy (CBT), and even supportive therapy for treatment of anxiety, though effects are greatest for relaxation training for anxiety symptoms and CBT for anxiety disorders. Relaxation training is a low-cost and effective intervention that can be used by a range of professionals in a variety of settings.
Wetherell and colleagues (2005) reviewed the literature and reported that progressive muscle relaxation, CBT, and even supportive therapy have empirical support documenting their efficacy for treating geriatric anxiety. However, the authors report that, when compared to waitlist and supportive control conditions, the psychological treatments with the greatest effect sizes (.20 or greater) are relaxation training (for anxiety symptoms) and CBT (for anxiety disorders).
- Cognitive behavioral Therapy (CBT).
- CBT has the strongest evidence for effective treatment of GAD.
- CBT is better tolerated than pharmacotherapy and studies suggest that CBT plus medication is no more effective than CBT alone.
- CBT also provides reductions in comorbid depression.
- CBT protocols include: problem solving skills training, behavioral activation, sleep hygiene, life review, and memory aids.
- CBT can be conducted either in group or individual formats.
In recent years, CBT has been shown to be superior to waitlist conditions, medication management-only conditions, supportive control conditions (e.g., supportive counseling, minimal contact, discussion group), and usual primary care (Barrowclough et al., 2001; Gorenstein et al., 2005; Mohlman et al., 2003; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell, Gatz, & Craske, 2003). In some of the other studies, compared to waitlist or supportive control conditions, CBT also provided greater reductions in comorbid depression, as well as improvements in QOL (Barrowclough et al., 2001; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell et al., 2003). However, in a recent study comparing CBT plus medication management with medication management alone, the combined approach was not found to be superior in reducing anxiety, worry, and total distress (Gorenstein et al., 2005). These mixed results warrant further understanding and research as to the most effective treatment approaches for late life anxiety
References
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Document Date: September 9, 2009
UPDATED JULY 2014
Zvi D. Gellis, PhD, University of Pennsylvania
Eunhae Grace Kim, MSW, Doctoral Candidate, University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
Anxiety Disorders in Older Adults Literature Review
Search Strategy
This review of the literature on Late Life Anxiety was undertaken to determine the extent of the problem, and the effectiveness of various psychosocial and pharmacological treatments. The term effectiveness is defined here as producing or capable of producing a desired effect in a controlled study. This review consists of systematic reviews, meta-analyses, other reviews of the literature, experimental and quasi-experimental designs, and case studies with older adults (65+) as participants, reported in English language peer-reviewed journals.
Keyword terms included: aged, aging, elderly, geri*, older adult, senior, anxiety, anxious, anxiety disorder, intervention, treatment, and randomized controlled trials. We conducted searches on the following databases: PubMed (1990-2013); PsychINFO (1972-2013); Ageline (1978-2013); Social Work Abstracts (1977-2013); and Social Sciences Abstracts (1983-2013). Relevant journals were hand searched to identify recent publications that would not have been cited or indexed. Unpublished literature was not included in the review.
Background and Significance
Epidemiological evidence suggests that anxiety is a common and major problem in later life, yet it has received less attention than depressive disorders. Anxiety disorders are often associated with common age-related medical and chronic conditions such as asthma, thyroid disease, coronary artery disease, dementia, and sensory loss (Diala & Muntaner, 2003). Anxiety in later life has been identified as a risk factor for greater disability among older adults in general, and has also been associated with less successful recruitment into, and outcomes of, geriatric rehabilitation services (Bowling, Farquhar, & Grundy, 1996). Researchers and practitioners are beginning to recognize that aging and anxiety are not mutually exclusive; anxiety is as common in the old as in the young, although how and when it appears is distinctly different in older adults. Additionally, there is a need for more effectiveness research on evidence-based treatments for late life anxiety (Mitte, 2005).
Recognizing an anxiety disorder in an older person poses several challenges. Aging brings with it a higher prevalence of certain medical conditions, realistic concern about physical problems, and a higher use of prescription medications. As a result, separating a medical condition from physical symptoms of an anxiety disorder is more complicated in the older adult. Diagnosing anxiety in individuals with dementia can be difficult, too: agitation typical of dementia may be difficult to separate from anxiety, impaired memory may be interpreted as a sign of anxiety or dementia, and fears may be excessive or realistic depending on the person’s situation.
Epidemiology: Anxiety Disorders
Although anxiety disorders, like most psychiatric conditions, may be less common among older adults than among younger people, epidemiological evidence suggests that anxiety is a major problem in late life (Salzman & Lebowitz, 1991; U.S. Department of Health & Human Services, 1999). A recent review by Wolitzky-Taylor (2010) reported the prevalence estimates of anxiety disorders in older adults, ranging from 3.2% (Forsell et al., 1997) to 14.2% (Ritchie et al., 2004). For example, the National Comorbidity Survey-Replication (NCS-R) reported 7% of older adults 65 and above met the anxiety disorder criteria within the past one year (Gum et al., 2009). Meanwhile, another study found that 33.7% of its participants, who were 55-years-old and older and currently diagnosed with Generalized Anxiety Disorder (GAD), reported an onset of GAD symptoms prior to being 50 years old (Chou, 2009).
One study involving interviews with nearly 6,000 people nationwide reported lifetime prevalence rates of 15.3% for DSM-IV-diagnosed anxiety disorders in respondents over age 60 (Kessler, Berglund, Demler, Jin & Walters, 2005). Another study of approximately 500 community-dwelling triethnic elders reported prevalence rates of 11.3% in blacks, 12.4% in Hispanics, and 21.6% in non-Hispanic whites age 75 and older (Ostir & Goodwin, 2006). Myers et al. (1984) report a six month prevalence of anxiety disorders in late life ranging from 6.6% to 14.9% across three Epidemiologic Catchment Area (ECA) sites. Comparable data from the Netherlands indicate a prevalence of 10.2% (Beekman et al., 1998). Anxiety disorders overall appear to be the most common class of psychiatric disorders among older people, more prevalent than depression or severe cognitive impairment (Beekman et al., 1998; Kessler et al., 2005; Regier et al., 1988).
Epidemiology: Phobias and Generalized Anxiety Disorder
Prevalence estimates for Generalized Anxiety Disorder among older adults range from 1.2% (Gum et al., 2009) to 7.3% (Beekman et al., 1998). Few studies have reported the prevalence estimates of social phobia among older adults and those estimates were relatively low, ranging from 0.6% (Trollor et al., 2007) to 2.3% (Gum et al., 2009; Wolitzky-Taylor, 2010).
Phobias and GAD account for most anxiety disorders in late life (Beekman et al., 2000; Flint, 2005; Hybels & Blazer, 2003; LeRoux, Gatz & Wetherell, 2005; Wolitzky-Taylor & Castriotta, 2010). Reviews summarized the prevalence of specific anxiety disorders in older community-based epidemiological samples as follows: phobias, including agoraphobia and social phobia, 0.7-12.0%; GAD, 1.2-7.3%; obsessive-compulsive disorder, 0.1-1.5%; and panic disorder, 0.0-0.3% (Alwahhabi, 2003; Beekman et al., 1998; Beekman et al., 2000; Krasucki, Howard, & Mann, 1998). Prevalence of GAD in older adults was estimated at 1.9% in the ECA sample and 7.3% in the Dutch sample (Beekman et al., 1998; Beekman et al., 2000; Blazer, 1997). Among people 55 years of age and older, Douchet, LaDouceur, Freeston & Dugas (1998) found that 12.8% meet criteria for GAD. By comparison, ECA prevalence rates for older adults are 1.8% for major depression, 2.8% for dysthymia, and 4.9% for severe cognitive impairment (Blazer, 1997; Regier et al., 1988).
Epidemiology: Subthreshold Anxiety Symptoms
The prevalence of clinically significant anxiety, including symptoms that do not meet criteria for a specific disorder, is common among older adults and may be as high as 20-29% (Davis, Moye, & Karel, 2002; Lenze et al. 2005). Grenier et al. (2011)’s large study reported the sum of the syndromal and subthreshold anxiety estimates as 26.2%. This includes anxiety symptoms associated with common medical conditions such as asthma, thyroid disease, coronary artery disease, and dementia, as well as adjustment disorders following significant late life stressors such as bereavement or caregiving. There is also controversy over whether the prevalence of anxiety has been accurately determined in older adults, because DSM-IV criteria may not apply as well, anxiety symptoms may be expressed as somatic features or behavior changes (e.g., aggression, assaultive behaviors), and the clinical presentation of anxiety in late life may be more likely to include depressive symptoms (Beck, 2004; Diefenbach & Goethe, 2006; Fuentes & Cox, 1997; Kim, Braun, & Kunik, 2001; Palmer, Jeste, & Sheikh, 1997).
Risk Factors
Aging per se is not a risk factor for anxiety but rather a protective one (Acierno et al., 2006). However, several biological, psychological, and social risk factors for anxiety disorders have been identified for older adults. Biological risk factors include: chronic health conditions (Schoevers et al., 2003), poor self-perception of health (van Zelst et al., 2003), and functional limitation (Schoevers et al., 2003). Psychological risk factors include: external locus of control, poor coping strategies, neuroticism, and psychopathology (Schoevers et al., 2003; van Zelst et al., 2003). Social risk factors include: low frequency of contact (Forsell, 2000), smaller network (Beekman et al., 1998), lack of social support (Forsell, 2000; Beekman et al., 2000), loneliness (van Zelst et al., 2003), stressful life events (van Zelst et al., 2003), lower education level (Beekman et al., 1998), being female (Schoevers et al., 2003; van Zelst et al., 2003).
Comorbidity Issues
Medical Comorbidity
The high comorbidity of anxiety with medical illness is multidimensional. Anxiety is complex and may be a reaction to a medical illness, may be expressed as somatic symptoms, or may be a side effect of medications. Studies have found an association between anxiety and medical illnesses such as diabetes (Blazer, 2003), dementia (Wrag & Jeste, 1989), coronary heart disease (Artero, Astruc, Courtet, & Ritchie, 2006; Kuzbansky, Cole, Kawachi, Vokonas, & Sparrow, 2006; Todaro et al., 2007), cancer (Deimling et al., 2006; Goodwin, Zhang, & Ostir, 2004; Ostir & Goodwin, 2006) chronic obstructive pulmonary disease (Karajgi, Rifkin, Doddi, & Kolli, 1990; Vogele & von Leupoldt, 2008), postural disturbance & vestibular disease (Gagnon et al., 2008), chronic pain (El-Gabalawy et al., 2011), and Parkinson’s disease (Stein, Heuser, Juncos, & Uhde, 1990; Pontone et al., 2009). For example, several studies have found that 18% (Yohannes et al., 2000) to 50% (Dowson et al., 2001) of older adult patients with chronic obstructive pulmonary disease reported significant anxiety symptoms. Todaro et al. (2007) reported that 36% of study cardiac patients (Mean Age: 60) were currently diagnosed with an anxiety disorder and 45.3% in their lifetime. Another study noted that anxiety symptoms were found to be associated with future development of coronary heart disease (Caminero et al., 2005). In several studies of Parkinson’s disease patients, approximately 40-43% reported significant anxiety symptoms (Menza et al., 1993; Pontone et al., 2009). Comorbid anxiety and medical illness is associated with increased mortality. For example, anxiety is associated with greater risk for mortality for patients after heart surgery (Tully et al., 2008) while panic attacks are associated with increases in risk for cardiovascular mortality (Smoller et al., 2007). At least one tri-ethnic study found that anxiety was associated with increased risk for death from all causes in persons 75 years and older (Ostir & Goodwin, 2006).
Psychiatric Comorbidity
Depression: As with young adults, anxiety in older adults has been found to often co-occur with depression (Beck, 2004; Beekman et al., 1998; Blazer, 1997; Byers et al., 2010; Heck et al., 2011; King-Kallimanis et al., 2009; Schoevers et al., 2003; Steffens et al., 2005;). Furthermore, anxiety symptoms have been found to lead to depressive symptoms (Wetherell, Gatz, & Pederson, 2001). In fact, community survey research has revealed that the comorbidity of anxiety and depression has been found to be as high as nearly 50% among older adults (Beekman et al., 2000). In the community study, 25% of older adults with anxiety also had major depression. Related to this, up to 50% of older adults with major depression had a comorbid anxiety disorder (Beekman et al., 2000; Blazer, 2003; Jeste, Hays & Steffens, 2006). Large community-based studies have shown a positive association between the comorbid GAD and depression, and its chronicity (Schoevers et al., 2005) and severity (Hopko et al., 2000) compared to GAD or depression alone. Depressed older adults with GAD symptoms have shown greater suicidality (Lenze et al., 2000; Bartels et al., 2002), treatment non-responsiveness (Mulsant & Wright, 1996), and a likelihood of treatment dropout (Flint & Rifat, 1997) when compared to those without anxiety.
Mood & Personality Disorders: Older adults with GAD often also suffer from other psychiatric disorders. The majority of GAD patients have mood disorders (Flint, 2005; Lenze et al., 2005). For example, bipolar disorder has been found to often co-occur with anxiety for older adults (Sajatovic et al., 2006). Approximately 20% of older adults with bipolar disorder report lifetime rates of generalized anxiety disorder (Goldstein, Hermann & Shulman, 2006). In addition, personality disorders often co-occur with GAD (Mackenzie et al., 2011). When compared to those without anxiety, older adults with anxiety have reported a greater prevalence of personality disorders such as avoidant and dependent personality disorders (Coolidge et al., 2000).
Cognitive Impairment: Older adults with anxiety often also suffer from cognitive impairment and dementia (Beaudreau et al., 2008; Forsell et al., 2003; Potvin et al., 2011; Seignourel et al., 2008; Sinoff & Werner, 2003; Wilson et al., 2011). Approximately 5% to 21% of older adult dementia patients have anxiety disorders (Feretti et al., 2001; Skoog, 1993). These prevalence estimates are greater when compared with those for cognitively intact persons (Hwang, Masterman, Ortiz, Fairbanks, & Cummings, 2004; Lyketsos et al., 2002; Tatsch et al., 2006). Individuals with anxiety symptoms have done poorly on assessments of cognitive functioning (Schultz, Moser, Bishop, & Ellingrod, 2005; Sinoff & Werner, 2003). Also, when compared to those without psychiatric disorders, those with GAD have shown poorer short-term memory (Mantella et al., 2007). Studies using community samples have found Alzheimer’s disease to be positively associated with anxiety symptoms (Geda et al., 2004; Hwang et al., 2004).
It is possible that the prevalence of anxiety is higher in primary care settings than in the community at large. Krasucki et al. (1999) found that, in primary care settings, 30% of older adults present with generalized anxiety symptoms. Distressed older adults seeking help typically present to their primary care physician (Smyer & Gatz, 1995). Prevalence estimates of anxiety symptoms among older adult patients range from 15% in the geriatric hospital (Ames et al., 1994) to 56% in the general hospital (Ames & Tuckwell, 1994). Meanwhile, prevalence estimates of anxiety disorders range from 1% in the general hospital (Ames & Tuckwell, 1994) to 24% in primary care (Tolin et al., 2005). Older adults with anxiety disorders are less likely than older adults with depression, dementia, or any other mental disorder to receive treatment from a mental health specialist (Ettner & Hermann, 1997).
In an analysis of data from the 1997 National Ambulatory Medical Care Survey, a national probability sample survey of physician office visits, anxiety disorder diagnoses were assigned for 1.3% of visits by older patients, with anxiety disorder not otherwise specified as the most frequent diagnosis (Stanley, Roberts, Bourland, & Novy, 2001). Because evidence suggests that only approximately one-third of such cases are detected in primary care (e.g., Kessler, Lloyd, Lewis, & Gray, 1999), these data likely represent a substantial underestimate of the prevalence of anxiety in that setting. Furthermore, Levy, Conway, Brommelhoff, & Merikengas (2003) found that, compared to younger adults, older adults tend to minimize and underreport their anxiety symptoms. Thus the prevalence rate of older adults who experience anxiety may be underestimated (Levy et al., 2003).
There is a dearth of research on anxiety and anxiety disorders in older adults with hearing or visual impairment, with previous studies in this population focusing primarily on depression and functional impairment. However, one recent study by Brenes et al. (2005) found significantly higher levels of anxiety in a national sample of 1,002 older disabled women who reported experiencing visual problems. Overall, it appears that anxiety symptoms and syndromes are quite common in old age, and may be detectible at even higher levels in older adults with visual deficits.
Consequences of Anxiety Disorders
The consequences of anxiety in late life are potentially serious. In a prospective investigation, anxiety did not generally remit spontaneously over 2 to 3 years (Livingston, Watkin, Milne, Manela, & Katona, 1997). Hypertension, hypoglycemia, and coronary heart disease can be worsened through chronic stress and anxiety (Hersen & Van Hasselt, 1992). Compared with men reporting no symptoms of anxiety, men in the Normative Aging Study reporting two or more anxiety symptoms had elevated risk of fatal coronary heart disease (Kawachi, Sparrow, Vokonas, & Weiss, 1994). Higher levels of anxiety have been associated with greater use of pain-relieving medications and more postoperative disability days for surgical patients (Taenzer, Melzack, & Jeans, 1986). Anxiety was also related to pain in a sample of nursing home residents (Casten, Parmelee, Kleban, Lawton, & Katz, 1995).
Anxiety symptoms and disorders are associated with increased fatigue, greater levels of chronic physical illness, increased disability, lower levels of well-being, worse life satisfaction, and inappropriate use of medical services among older adults (Martin, Bishop, Poon, & Johnson, 2006; Brenes et al., 2005; de Beurs et al., 1999; Hunt, Issakidis, & Andrews, 2002; Jones, Ames, Jeffries, Scarinci, & Brantley, 2001; Wetherell et al., 2004; Wittchen, Carter, Pfister, Montgomery, & Kessler, 2000). Furthermore, a sample of older adults with GAD reported impairments on quality of life (QOL) measures that were worse than impairments reported by another group of age-matched individuals who had serious medical conditions such as myocardial infarction or type II diabetes (Wetherell et al., 2004). It was also found that the reported QOL impairments for the individuals diagnosed with GAD was comparable to those reported for people with major depression. In cases of comorbid anxiety and depressive disorders, the likelihood of poor outcomes increases. Comorbid anxiety in late-life depression is associated with poor treatment response and increased likelihood of dropout (Lenze, Mulsant, et al., 2003). Also, older people with anxious depression report increased suicidality and reduced psychosocial support (Jeste et al., 2006).
In addition to direct relationships with poorer health care outcomes, anxiety and depression have been associated with markedly higher health care costs among age-matched groups of primary care patients, even after adjustment for medical comorbidity (Simon, Ormel, VonKoff, & Barlow, 1995). During office visits, older adults with anxiety spend 50% more time with their primary care physician than older adults with no psychiatric diagnosis do (Stanley et al., 2001). Taken altogether, these findings support the importance of treatment of anxiety in late life.
Treatments
Pharmacological Treatment
In part because of the tendency for older adults to present to primary care physicians, anxiolytic medications, including benzodiazepines, are the most common treatment for late life anxiety (Lenze, Pollock, et al., 2003). ECA data suggests that benzodiazepine use among the elderly is approximately 14%, higher than the rate for younger adults (Swartz, Landerman, George, Melville, Blazer, & Smith, 1991). A community survey of older adults in southern California showed that 20% had used benzodiazepines at least twice in the previous 12 months; these individuals were more than twice as likely as nonusers to take 10 or more drugs (Mayer-Oakes et al., 1993).
Benzodiazepine users are also more likely than nonusers to experience accidents requiring medical attention, due to increased risk of falls, hip fractures, and automobile accidents (Tamblyn, Abrahamowicz, du Berger, McLeod, & Bartlett, 2005). Older patients taking benzodiazepines are also more likely to develop disabilities in both mobility and activities of daily living (ADLs) (Gray et al., 2006). Benzodiazepines can impair memory and other cognitive functions (Wengel, Burke, Ranno, & Roccaforte, 1993). These medications can also cause tolerance and withdrawal, interactions with other drugs, and toxicity (Krasucki et al., 1999; Salzman & Lebowitz, 1991).
Although safer medications than benzodiazepines, particularly selective serotonin reuptake inhibitors (SSRIs), are often used to treat geriatric anxiety, they can cause unpleasant side effects, and some older people prefer not to take them. Furthermore, SSRIs have not completely replaced benzodiazepines as a treatment for anxiety in older people (Keene, Eaddy, Nelson, & Sarnes, 2005). Safe and effective alternative treatments for anxiety that are appealing to an older population are clearly needed.
Psychosocial Treatment
The efficacy of evidence-based psychosocial interventions has been tested using randomized trials for geriatric anxiety and reviewed with emerging evidence of support for their use (Ayers, Sorrell, Thorp, & Wetherell, 2007) (Level A; see Chapter 1, Introduction for description of Levels).
Several studies have provided some support for the use of relaxation training and cognitive behavior therapy (CBT) for treatment of anxiety (Barrowclough et al., 2001; Gorenstein et al., 2005; Mohlman et al., 2003; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell, Gatz, & Craske, 2003) (Level A). In recent years, CBT has been shown to be superior to waitlist conditions, medication management-only conditions, supportive control conditions (e.g., supportive counseling, minimal contact, discussion group), and usual primary care (Barrowclough et al., 2001; Gorenstein et al., 2005; Mohlman et al., 2003; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell et al., 2003) (Level A). In a study by Gorenstein and colleagues (2005), greater reductions in anxiety were not seen until a 6-month follow-up visit. In some of the other studies, compared to waitlist or supportive control conditions, CBT also provided greater reductions in comorbid depression, as well as improvements in QOL (Barrowclough et al., 2001; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell et al., 2003). However, in a recent study comparing CBT plus medication management with medication management alone, the combined approach was not found to be superior in reducing anxiety, worry, and total distress (Gorenstein et al., 2005). While some studies suggest that CBT is promising for the treatment of anxiety, Stanley, Beck, and Glassco (1996) found no differences between CBT and supportive psychotherapy on anxiety and depression reductions. Finally, in another review by Wetherell, Sorell, Thorp, and Patterson (2005), the authors assert that progressive muscle relaxation, CBT, and even supportive therapy have empirical support for their use in treating geriatric anxiety (Level B). However, the authors report that, when compared to waitlist and supportive control conditions, the psychological treatments with the greatest effect sizes (20 or greater) are relaxation training (for anxiety symptoms) and CBT (for anxiety disorders). These mixed results warrant further understanding and research as to the most effective treatment approaches for late life anxiety.
Summary: Take Home Points for Teaching
- Anxiety is a common problem in late life.
- Anxiety is more prevalent than depressive disorders in later life.
- Generalized Anxiety Disorder (GAD) is the most common (prevalence rate 1.2-7.3%).
- Subthreshold anxiety symptomology is higher than GAD (prevalence rate 20-29%).
- Prevalence of anxiety symptoms is likely higher in primary care settings (~30%) than in the community at large or any other setting.
- Less common are phobias, Obsessive-Compulsive Disorder, and panic disorders.
- Comorbidity with depression is high (nearly 50%).
- It is difficult to disentangle anxiety from depression during assessment.
- Risk factors for anxiety include chronic health conditions, poor health self-perception, poor coping strategies, lack of social support, and lower level of education.
- Comorbidity with medical illnesses is high.
- Negative outcomes of anxiety include poor health outcomes, poor life satisfaction, significant functional impairment, increased Emergency Room and primary care visits, and higher medical costs.
- Pharmacological Treatments: Benzodiazepines are the most common medication treatment for late life anxiety; SSRIs are safely used but have unpleasant side effects.
- Psychosocial Treatments:
- Evidence has been found for Cognitive Behavioral Therapy (CBT) (Level A), Relaxation Training (Level A), and to a lesser extent Supportive Therapy (Level C).
- CBT has the strongest evidence to date for treatment of Generalized Anxiety Disorder in comparison to control groups.
- CBT is better tolerated than pharmacotherapy.
- Relaxation training is viewed as a low-cost, effective intervention.
- CBT protocols can include problem-solving skills training, behavioral activation, sleep hygiene, life review, and memory aids.
- CBT can be conducted in individual or group formats.
- CBT has been found to be more effective than Supportive Therapy or Attention Placebo conditions.
- CBT combined with medication management has been found to be no better than CBT alone.
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Document Date: September 9, 2009
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Document Date: September 9, 2009
Mrs. C. is a 76-year-old woman who lives alone in an apartment in a quiet residential neighborhood. She frequently contacts her primary care physician (PCP) with concerns about her health. When seen by her PCP, she expresses a number of worries about other areas of her life. For example, she has concerns about the safety of the neighborhood where she lives, she worries about her finances even though she receives both social security and a retirement pension from teaching school, and she worries that other people avoid her because she is no fun to be around. She states that she has always been a “worry wart” and that this constant worry has made her life difficult. She states that she has difficulty concentrating and making decisions. She reports feeling restless and having difficulty going to sleep because of excessive rumination about her worries. She states that she feels fatigued and doesn’t feel like doing anything.
Activity #1. Have students divide into pairs. In the first part of the exercise, one student will be Mrs. C. and the other will be a social worker working in the ambulatory care clinic where Mrs. C’s PCP sees her. Ask the social worker to use Lang and Stein’s Useful Questions to elicit information about anxiety and about physical symptoms. The student portraying Mrs. C. will use the information provided in the vignette plus other information as needed to complete the clinical picture and context (e.g., symptoms, cultural factors, environment, family) as needed to develop the role. After the initial screening and overview, ask the students to switch roles.
Activity #2. Students should switch roles. The new social worker will either conduct a HAM-A interview and rate the symptoms or will introduce and administer BAI and review Mrs. C.’s scores with her after she completes the BAI.
Activity #3. Based on information gathered in the screening and the HAM-A/BAI, have the pair work together to develop a hypothetical plan. What should be done? By whom? [Activity #3 may be delayed until after the section on treatment, if desired.]
Document Date: September 9, 2009
Download this PowerPoint for Chapter 2 of the Mental Health Resource Review.
Document Date: September 9, 2009
Zvi D. Gellis, PhD. University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago.
Depressive Disorders in Older Adults
Significance of Depression among Older Adults
- Depression is a frequent cause of distress in older adults; leads to physical, mental, and social dysfunction; and significantly decreases quality of life.
- Increasing percentage of U.S. population will be 65+ over next decade with an increasing prevalence of African American, Latino, and Asian Americans who have more difficulty accessing healthcare services.
- Older adults may be reluctant to seek services for depression because of mental illness stigma, fear of jeopardizing health care, and insurance. They may also fear loss of financial security and independence, embarrassment, isolation, or being declared incompetent. Service access barriers including limited financial resources, language barriers, and a lack of culturally-sensitive programs are other reasons for not seeking treatment.
- Sometimes, due to fragmented mental health services or gaps in services, older adults do not receive appropriate care when they do seek help. Financial constraints of managed care are increasingly restricting the time spent with clients, forcing mental health concerns to compete with comorbid medical conditions.
Between the years 2015 and 2030 older adults (65 years+) will account for 20% of the total population, up from 13% in 2000 (U.S. Bureau of the Census, 2000). Added to this trend is the increasing proportion of minority older adults including African-American, Latino, and Asian-Americans (Areán et al., 2005; Gellis & Taguchi, 2003; Harada & Kim, 1995), who tend to have more obstacles than Caucasians do in accessing mental health services. According to the Surgeon General’s Mental Health Report, depression in older adults leads to physical, mental, and social dysfunction (U.S. Department of Health and Human Services [DHHS], 1999). Primary care physicians often report feeling too pressured for time to investigate mental health problems in older people (Glasser & Gravdal, 1997).
Epidemiology of Depression in Older Adults
- Rates of depression vary widely in older adults in different settings, and the rate of clinically significant depressive symptoms is even higher than the rate of diagnosable depressive disorders.
- Community dwelling older adults. Major depression: 1-4% overall (higher among women); dysthymia: ~2%; minor depression: 4-13% (similar distribution across gender, race, and ethnicity).
The prevalence estimates of major depression in community elderly samples are low, ranging from 1 to 4% overall, with a higher prevalence among women. The prevalence rate for dysthymia is about 2% although for minor depression estimates are higher, ranging from 4 to 13% with the same pattern of distribution across gender, race, and ethnicity (Blazer, 2002; Beekman et al., 1995). There are no significant racial or ethnic differences in prevalence rates for depression (Beekman, Copeland, & Prince, 1999; Steffens et al., 2000; Zalaquett & Stens, 2006).
- Medically ill older adults. Major depression: 10-12%; significant depressive symptoms: 23%. Rates of clinically significant depressive symptoms among medically ill elderly: 10-43%.
- Home health care. Major depression: 13.5%; significant depressive symptoms: 27.5%. Depression twice as prevalent in home health care as in primary care; it is persistent, intermittent, and associated with medical illness, pain, and disability.
- Depression is one of the most common mental disorders in primary care and home health care settings.
Estimates for rates of major depression in medically ill elderly range from 10-12% with an additional 23% experiencing significant depressive symptoms (Koenig, Meador, Cohen, & Blazer, 1988). In home health care, estimates of 13.5% for major depression and 27.5% for significant depressive symptoms were found (Bruce et al., 2002; Gellis, 2006). Rates of clinically significant depressive symptoms among medically ill elderly range from 10 to 43% (Williams-Russo, Sharrock, Mattis, Szatrowski, & Charlson, 1995; Peterson, Williams-Russo, Charlson, & Myers, 1996; Steffens et al., 2000). In fact, depression is twice as prevalent in home health care as in primary care; it is persistent, intermittent, and is associated with medical illness, pain, and disability (Lyness, King, Cox, Yoediono, & Caine, 1999). Late life depression is one of the most common mental disorders to present in primary care and home health care settings (Bruce et al., 2002; Gellis & Kenaley, 2008; Gellis, McGinty, Horowitz, et al., 2007; Lyness et al., 1999; Reynolds & Kupfer, 1999). Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes.
- Long-term care. Major depression: 6-24%; minor depression and dysthymia: 30-50%; subthreshold clinically significant depressive symptoms: 35-45%. Depression often is undetected in long-term care and when detected is inadequately treated.
Prevalence rates of depression in long-term care vary depending on study definitions and measures used. For elderly patients with major depression, rates range from 6 to 24% in nursing homes (Blazer, 2002). Prevalence estimates for minor depression and dysthymia are even higher and range from 30 to 50% in the majority of studies; and for subthreshold clinically significant depressive symptoms, the range is 35 to 45% (Hyer, Carpenter, Bishmann, & Wu, 2005). Depression is underdetected in long-term care facilities and if detected, is inadequately treated (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001; Brown, Lapane, & Luisi, 2002).
- Prognosis of depression among older adults can often be poor. Depression predicts poor treatment adherence, may exacerbate other common chronic medical conditions, slows recovery from other illnesses and surgery, and is associated with increased mortality.
A meta-analysis of depression outcomes at 24 months estimated that only 33% of older patients were well, 33% were depressed, 13% were hospitalized, and 21% had died (Cole, Bellavance, & Mansour, 1999). Depression is also an independent predictor of overall poor treatment compliance and may exacerbate other common chronic medical conditions in older adults (DiMatteo, Lepper, & Croghan, 2000). Moreover, late life depression slows recovery rates from illnesses and surgeries and is associated with increased mortality (Beekman et al., 1999; Unützer et al., 2003).
- Risk factors for depression among community-dwelling older adults includes female gender, sleep disturbance, disability level, prior history of depression, and bereavement.
Cole and Dendukuri (2003) completed a systematic review of risk factors for depression in community-dwelling elderly that involved a qualitative and quantitative synthesis of the data. They examined 20 studies and identified key risk factors that included female gender, sleep disturbance, disability level, prior history of depression, and bereavement.
Comorbidity of Depression in Older Adults
- Comorbidity of depression with physical disorders is common and negatively influences the course of the depression, increases functional impairment, health costs, and use of health services.
- Common medical illnesses known to be associated with depression include heart disease, stroke, hypertension, diabetes, cancer, and osteoarthritis.
Depression with physical illness increases levels of functional disability (Alexopoulos et al., 1996; Proctor et al., 2003), use of health services (Beekman, Deeg, Braam, Smit, & van Tilburg, 1997; Saravay, Pollack, Steinberg, Weinsched, & Habert, 1996), and health care costs (Callahan, Kesterson, & Tierney, 1997; Manning & Wells, 1992; Simon, VonKorff, & Barlow, 1995), particularly among older adults (Unützer et al., 1997). It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996).
Depression and Suicide in Older Adults
- The suicide rate among older adults is twice that of the general population accounting for about 20% of all suicides, though they are only 13% of the population. Males 85 and over have the highest suicide rate of any age group, and males over 80 take their lives at twice the rate of women.
- Risk factors for suicide among older adults.
- Medications: Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are effective in treating anxiety disorders. They are used less frequently since the development of newer antidepressants, such as serotonin selective reuptake inhibitors (SSRIs).
- Demographic: Older age, male gender, white race, and unmarried status.
- Clinical: Depression (especially late-onset unipolar depression), comorbid anxiety, substance abuse, isolation, loneliness, lack of social supports, and declining physical health.
- Over 70% of older suicide victims had had contact with their primary care physician in the 3 months prior to the suicide. The majority of older patients had late onset undetected or untreated depressive symptoms, likely reflecting high rates of comorbid illness and/or fears of pain or dependency on others.
In the elderly, suicide is almost twice as frequent as in the general population (Conwell, Duberstein, & Caine, 2002. The elderly account for 20% of all suicides, yet they make up only 13% of the population (Hoyert, Kung, & Smith, 2005; Pearson & Brown, 2000). Some of the most common demographic correlates of suicide are older age, male gender, white race, and unmarried status (Peters, Kochanek, & Murphy, 1998). In the U.S., older white males age (85+) have the highest suicide completion rates (65 per 100,000) (U.S. Dept. of Health and Human Services, 2003), over six times the rate of all age-adjusted suicides (Peters et al., 1998). Men 80+ take their own lives at four to six times the rate of older women (Scocco & DeLeo, 2002). Depression, comorbid anxiety, substance abuse, isolation, loneliness, lack of social supports, and declining physical health are some of the risk factors for suicide among older adults (Conwell et al., 2002). Retrospective studies identified that greater than 70% of older suicide victims have had contact with their primary care provider within 3 months prior to their death (Conwell, Olsen, Caine, & Flannery, 1991; Conwell, 1994; Diekstra & van Egmond, 1989; Frierson, 1991; Uncapher, 2000). In these studies, the majority of older patients had late onset undetected or untreated depressive symptoms, likely reflecting high rates of comorbid illness and/or fears of pain or dependency on others (Duberstein, 1995).
- During the past decade, attention to detecting and treating depression in healthcare settings have led to reduced rates of depression.
- A large multisite randomized trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) enrolled patients with different types of depression and conducted follow-up studies with followed them for 2 years. Patients were offered medication or interpersonal therapy (IPT) and were seen regularly by care managers who monitored symptoms, adherence, treatment response, and side effects. Patients who received this intervention had less severe depression symptoms and higher remission rates than those who did not.
A large multisite randomized trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) enrolled patients who met criteria for major depression, dysthymic disorder, or minor depression and tracked their status for a period of 2 years through acute, continuation, and maintenance phases of treatment (Bruce & Pearson, 1999; Alexopoulos et al., 2005). The experimental intervention was implemented by depression care managers who monitored psychopathology, treatment adherence, response, and side effects at predetermined times. Patients were offered antidepressant medications and/or interpersonal psychotherapy, an evidence-based intervention. The PROSPECT trial demonstrated that elderly patients receiving a depression care management intervention had less severe depressive symptoms and greater remission rates at 4, 8, and 12 months than patients receiving usual primary care (Bruce et al., 2004).
- Suicide management.
- LISTEN: Take note of clues in what your clients say.Most people who are thinking about suicide will communicate their intent through clues. “I can’t go on”, “What’s the use?” “I gave some things away.”
- INQUIRE: Ask the client if (or how often) he/she is thinking about suicide.
- INFORM: Tell clients that you are concerned for their wellbeing.
- MYTH: “Asking someone about suicide will encourage it.” Not true.
- PLAN: Develop a safety plan with clients.
- REFER: Give clients referrals to mental health/psychiatric professionals.
Evidence-based Treatment of Depression in Older Adults
Psychosocial Interventions
- Psychosocial interventions have been demonstrated to be effective among older adults, particularly those who reject medication because of unpleasant side effects or who are coping with low social support or stressful situations.
- Evidence-based approaches such as structured problem-solving (PST) cognitive-behavioral (CBT), and interpersonal (IPT) therapies are effective intervention alternatives or adjuncts to medication treatment.
- Psychosocial interventions alone are effective with older populations including minorities. Cognitive therapies, including PST, are particularly promising among older men and women of diverse ethnic backgrounds.
- The majority of primary care patients prefer counseling over medication, which should be kept in mind since patient attitudes and preference affects acceptance of and adherence to the prescribed treatment for depression.
Psychosocial interventions have been demonstrated to be effective among older adults, particularly those who reject medication because of unpleasant side effects or who are coping with low social support or stressful situations (Choi & Morrow-Howell, 2007; Gellis, 2006). Evidence-based approaches such as structured problem-solving (PST) cognitive-behavioral (CBT), and interpersonal (IPT) therapies are effective intervention alternatives or adjuncts to medication treatment (Gath & Mynors-Wallis, 1997; Gellis, McGinty, Horowitz, et al., 2007; Hegel, Barrett, Cornell, & Oxman, 2002; Jacobson & Hollon, 1996; De Rubeis, Gelfand, Tang, & Simons, 1999; Schulberg, Pilkonis, & Houck, 1998).
There is evidence that psychosocial interventions alone are effective with older populations including minorities (Coulehan, Schulberg, Block, Madonia, & Rodriguez, 1997; Mossey, Knott, Higgins, & Talerico, 1996; Munoz, et. al., 1995). Cognitive therapies, including PST, are particularly promising (McCusker, Cole, Keller, Bellavance, & Berard, 1998; Nezu, 2004; Robinson et al., 1995) among older men and women of diverse ethnic backgrounds (Gil et al., 1996). Patient attitudes and preference for type of treatment has been shown to affect acceptance of and adherence to the prescribed treatment for depression (Schulberg, Magruder, & deGruy, 1996), and the majority of primary care patients prefer counseling over medication (Brody, Khaliq, & Thompson, 1997; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001).
- PST has been found to be effective in frail, homebound, medically ill individuals, and a short (6-week) course of treatment is as effective as medication in individuals with major and minor depression.
- Written educational materials for patients and family members improve medication adherence and clinical outcomes.
PST interventions for depression by non-medical mental health practitioners have also demonstrated effectiveness for homebound, frail, medically ill populations (Gellis, McGinty, Horowitz, et al., 2007; Mynors-Wallis, Gath, Davies, Gray, & Barbour, 1997). Adjunct written educational materials for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Some studies have found that 6 sessions of PST are as effective as pharmacotherapy among ambulatory primary care patients with minor and major depression (Hegel et al., 2002; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995).
- CBT (either individual or group) is at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy.
- Combined case management and CBT may have more efficacy than CBT alone for low-income and/or certain minority group members.
Literature reviews on the effect of CBT on late-life depression noted that CBT was at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy (Areán & Cook, 2002; Cuijpers, van Straten, & Smit, 2006; Laidlaw, 2001; Pinquart & Soerensen, 2001; Zalaquett & Stens, 2006).
Among low-income older adults with Major Depressive Disorder (MDD) or dysthymia, cognitive behavioral group therapy (CBGT) augmented with clinical case management and clinical case management alone led to greater improvements in depressive symptoms at the 12-month follow-up than did CBGT alone (Areán, Gum, & McCulloch, 2003). In a study of low-income older primary care patients with MDD, Spanish-speaking and English-speaking patients responded equally well to CBT alone versus case management (Miranda, Azocar, & Organista, 2003). Moreover, CBT and supplemental case management was associated with greater improvement in symptoms and functioning than CBT alone for Spanish speakers, but it was less effective for those whose first-language was English.
- IPT, another evidence-based intervention for late life depression, focuses on relationships and conflicts with family and friends. Its purpose is to improve communication in those relationships, and develop or enhance the social support network.
IPT is another evidence-based intervention for late life depression that focuses on the depressed person’s relationships and conflicts with family and friends (Hinrichsen, 1999). The overall purpose is to improve communication in those relationships and to develop or enhance the social support network of the identified depressed patient (Weissman & Markowitz, 1994). Several meta-analytic reviews noted findings of the efficacy of IPT for depression (de Melo, de Jesus, Bacaltchuk, Verdeli, & Neugebauer, 2005; Parker, Parker, Brotchie, & Stuart, 2006; Thase et al., 1997; Weston & Morrison, 2001).
- Adjunct written education materials for clients and family members improve medication adherence and clinical outcomes.
Educational materials written for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997).
- Treatment protocols for late life depression are typically time-limited (6-20 sessions) psychotherapeutic interventions.
- The goal of brief interventions is to treat the problem, specifically, changing the behavior of individuals who are experiencing mental health problems in later life. These psychosocial interventions include assessment and direct feedback, contracting and goal setting, cognitive and behavioral techniques, and the use of educational and other written materials.
- There is unfortunately less available evidence on culturally appropriate mental health treatments for older adults.
Interventions for depression generally range from 6 to 20 sessions, each lasting about an hour (Gellis, McGinty, Horowitz, et al., 2007; Hegel et al., 2002; Nezu, 2004; Nezu & Nezu, 2001).
- Interventions for approaching late-life depression.
- Questions to ask.
- How are things at home?
- How have you been coping?
- Have you had any stress lately?
- How are you handling it?
- Discuss your concerns with client. You can say:
- It is a very common
- It is a medical condition
- It is very treatable
- Prior to referral for mental health services:
- Be supportive. Be patient.
- Allow the individual to express his/her concerns/fears.
- Listen without being judgmental.
- Don’t take things personally if the client is irritated or angry.
- Provide choices and be complimentary.
- Attempt to provide daily activities.
- Guidelines for making a referral to a mental health program (from a non-mental health setting such as primary care, social service agency).
- If the older client has a psychiatric history.
- If there is suicidal ideation.
- If there is risk of suicide or you are concerned about client safety.
- If there is need for hospitalization.
- If client needs medication evaluation.
- If client needs ongoing therapy that can’t be provided in your setting.
Pharmacological Interventions
- Antidepressants are widely used and are safe and effective for the treatment of moderate to severe depression in older adults. All antidepressants are equally effective, though the most widely studied are tricyclic antidepressants and SSRIs. Medically ill older adults have fewer adverse effects with SSRIs, which has led them to be more widely prescribed in primary care settings.
- As older adults are prescribed more medications for other medical diseases, the likelihood of self-medication, multiple drug use, drug-drug interactions, and unpleasant side effects increases.
Based on several literature reviews of pharmacologic treatment for geriatric depression, antidepressants are safe treatments for depressed older adults (Barkin, Schwer, & Barkin, 2000; Mamdani, Parikh, Austin, & Upshur, 2000; Salzman, Wong, & Wright, 2002; Solai, Mulsant, & Pollock, 2001). Almost all antidepressant medications are equally effective for treating major depression (Blazer, Hybel, Simensick, & Harbin, 2000; Salzman et al., 2002). During the past two decades, over 30 randomized placebo controlled clinical trials as well as many comparative trials (Das Gupta, 1998; Salzman et al., 2002) have been conducted that have documented the efficacy and safety of antidepressant medications (Tricyclics and SSRIs) for older adults with depression. Naturalistic studies have shown that medically ill older adults have more adverse effects to trycyclics than to SSRIs (Cole, Elie, McCusker, Bellavance, & Mansour, 2001; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001), and the use of SSRIs in primary care has become more common (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003).
Minor Depression
- Minor (or subsyndromal) depression is more common among older adults than major depressive disorder.
- Prevalence of minor depression in older adults: community-dwelling: 10-30%; primary care: 5-9%; Latinos: 15%; Asian-Americans: 12%; African Americans: 10%.
- Minor depression is associated with increased risk of mortality in older men.
Minor depression, more often than major depression, is observed in numerous settings (Charney et al., 2003; Lavretsky & Kumar, 2002; Judd, Schettler, & Akiskal, 2002). Minor depression ranges from 10 to 30% in older community-dwelling adults (Hybels & Blazer, 2003) and approximately 5 to 9% in primary care settings (Lyness et al., 1999). Minor depression has been found to be associated with an increased risk for mortality in older men and to have a relatively high prevalence in some ethnic groups (Penninx et al., 1999). This subthreshold disorder is common in older minorities in primary care settings. As many as 15% of older Latinos, 12% of older Asian-Americans, and 10% of older African Americans meet the criteria for minor depression (Areán & Alvidrez, 2001).
- While the symptoms of minor depression remit over time, a substantial percentage of older adults continue to experience them many months later. For many, minor depression is a precursor to major depression.
- CBT, IPT, and PST approaches appear promising; however, further studies are needed to confirm their effectiveness.
A recent systematic review of adults and older adults diagnosed with minor depression found remission rates in the range of 46 to 71% after 3 to 6 years (Hermens et al., 2004). Two studies reported that 62% of adults and older adults still had minor depression at the 5-month follow-up evaluation, whereas 16% had persistent or recurrent minor depression at the 1-year follow-up (Broadhead, Blazer, George, & Tse, 1990; Penninx et al., 1999). At the 1-year follow-up, 12.7% of the adults originally with a diagnosis of minor depression had developed major depression (Broadhead et al., 1990). CPT, IPT, and PST models appear to be promising treatments for older adults with minor depression (Rowe & Rapaport, 2006). However, the research literature is less clear about these therapies effectiveness in minor depression compared to major depression because of the dearth of treatment studies, particularly among older adults.
Depression Screening
- The goal of screening is early identification and thus prevention through early intervention.
- Key criteria to be used by agency personnel to justify mental health screening for late life depression include the following:
- Is the national incidence of depressive disorders in the elderly population high enough to justify the cost of screening in an agency?
- Does the problem have a significant effect on the quality of life of the older adult?
- Is effective treatment available?
- Are valid and cost-effective screening instruments available?
- Are the adverse effects (if any) of the screening tests acceptable to social workers and older adult clients?
- The literature demonstrates the following (in relation to the above questions):
- Depression is prevalent among older adults in a wide variety of settings, and social workers encounter older adults in many areas of clinical practice.
- Depression among older adults causes serious health and social consequences.
- Effective psychosocial and pharmacological treatments are available for depression.
- Valid cost-effective depression screening procedures exist.
- Older adults do not find screening for depression aversive, outside the time and effort required to complete a short interview or form, if the need for the screening is explained clearly and the screening is conducted in an empathetic manner (Gellis & Kenaley, 2008; Gellis & Taguchi, 2003).
- A number of standardized rating scales for assessing the presence and severity of depressive symptoms in long-term care include self-reports such as the Center for Epidemiological Studies-Depression Scale (CES-D), Geriatric Depression Scale (GDS), Zung Self-Rating Depression Scale, Beck Depression Inventory (BDI), the Patient Health Questionnaire-9 (PHQ-9), and clinician-interview instruments including the Hamilton Rating Scale for Depression (HAM-D), and the Cornell Scale for Depression in Dementia (CSDD). All the measures are frequently used in long-term care settings (see Table 1 for citation and download information).
- For DSM diagnosis.
- Structured Clinical Interview for DSM-IV (SCID).
- Mini-International Neuropsychiatric Interview (MINI) is available in several languages. Register and download the instrument free at: https://www.medical-outcomes.com/indexSSL.htm.
- Steps in screening:
- Obtain the person’s agreement to be screened.
- Explain the purpose for the screening.
- Administer and score the screening tool as instructions direct.
- If the screen is positive, make initial treatment referrals for further diagnostic assessment to the older person’s primary care physician for possible psychotherapy and antidepressant medication.
- The social worker is in a unique position to:
- Identify resources if financial barriers exist.
- Address stigma through psychoeducation.
- Encourage client follow through with the referral.
Special Settings
Late Life Depression in Primary Care
- Integrating specialty mental health care within primary care has been found to be more effective than efforts to improve the psychiatric skills of primary care physicians. Multifaceted collaborative care approaches packages involve nurses, social workers, or other depression care managers, and vary in content and intensity.
- These interventions often aim to increase knowledge about depression (psychoeducation), improve adherence to antidepressant medication, improve physician-patient communication, and decrease depressive symptoms.
Much effort has been expended trying to improve the psychiatric skills of primary care physicians, but with only modest effects (Lin et al., 1997; Rihmer, Rutz, & Pihlgren, 1995). Integration of specialty mental health care within primary care and system of care enhancements, such as “collaborative or integrative care” are found to be more effective (Meyers, 1996; Schulberg et al., 1998; Gilbody, Whitty, Grimshaw, & Thomas, 2003). Collaborative care approaches are multifaceted intervention packages that involve nurses, social workers, or other depression care managers, and vary in content and intensity (Katon et al., 1999; Swindle et al., 2003). These interventions often aim to increase knowledge about depression (psychoeducation), improve adherence to antidepressant medication, improve physician-patient communication, and decrease depressive symptoms (Unützer et al., 2001; Von Korff & Goldberg, 2001).
- Effective components of educational and organizational interventions to improve depression management in primary care settings include: enhanced depression care manager role, clinician education, and improvement in communication between primary care provider and psychiatry liaison. Documentation alone of simple practice guidelines and educational strategies were generally ineffective.
A systematic review of 21 studies on educational and organizational interventions to improve depression management in primary care settings found positive results (Gilbody et al., 2003). Intervention components that were found effective included enhanced depression care manager role, clinician education, and improvement in communication between primary care provider and psychiatry liaison. Documentation alone of simple practice guidelines and educational strategies were generally ineffective.
- PST alone and in combination with medication and other components such as enhanced education and support, social and physical activation, self-care management, information and decision-making, counseling and support, and communication with primary care providers have been found to be effective.
A recent systematic review of 22 studies on PST was undertaken to determine the effectiveness of PST on reducing depressive symptoms in noninstitutionalized adults 18 years and older (Gellis & Kenaley, 2008. Four studies employed a multi-faceted intervention (Ciechanowski et al., 2004 [Program to Encourage Active, Rewarding Lives for Seniors or PEARLS]; Doorenbos et al., 2005; Katon et al., 2004; Unützer et al., 2002 [IMPACT]). The studies found that combined use of PST and antidepressant treatment had more favorable depression outcomes compared with PST alone. (To view a description and synopsis of the research on IMPACT and PEARLS go to: http://www.nrepp.samhsa.gov/listofprograms.asp?).
- Studies of multifaceted collaborative care of depression have found that mental health training background of staff, systematic identification of patients, and continuous depression specialist supervision predict good depressive symptom outcomes.
In a systematic review of 34 studies of multifaceted collaborative care interventions with outcome data on depressive symptoms and 28 studies on antidepressant medication use, positive effects were found for both antidepressant use and depressive symptom reduction (Bower, Gilbody, Richards, Fletcher, & Sutton, 2006). The studies reviewed found no variables that predicted variation of effectiveness by antidepressant medication use. Nonetheless, several key predictors of good depressive symptom outcomes were found, including mental health training background of staff, systematic identification of patients, and continuous depression specialist supervision.
- Collaborative management home care is another promising approach to the management of depression in older adults.
Flaherty and colleagues (1998) found that a collaborative management home care intervention for depression resulted in lower hospitalization rates (23.5%) compared to that of an historical control group (40.6%). A randomized controlled trial with blind follow-up evaluation 6 months after recruitment found that psychogeriatric team home care versus usual primary care improved depressive outcomes for 58% versus 25% of people 65 and over (Banerjee, Shamash, Macdonald, & Mann, 1996).
Late Life Depression in Home Health Care
- Home care services are essential to maintaining elders with disability in the community and reducing their hospitalization and nursing home use. Compared with the general elderly population, home care recipients are older, more socially isolated, more likely to be women, and more likely to have high rates of physical illness, disability, and depression. Unfortunately, many individuals with depression do not receive treatment.
- A variety of factors interact to interfere with the detection and treatment of depression in older adults.
- The heterogeneity of depression coupled with physical and cognitive impairment, social vulnerabilities, and various medical conditions prevalent in health care make it more difficult for accurate assessment, diagnosis, and treatment in the elderly population.
- Older adults are less likely to voluntarily report affective symptoms of depression, more likely to ascribe symptoms to a physical illness, and less likely to use specialty care.
Compared with the general elderly population, home care recipients are older, more socially isolated, more likely to be women, and more likely to have high rates of physical illness, disability, and depression (Banerjee, 1993). However, few elderly persons receive appropriate treatment of depression. For instance, in two studies only 21% (Brown, McAvay, Raue, Moses, & Bruce, 2003) and 16% (Banerjee et al., 1996) received treatment.
The client, treating physician, and health care organizational factors interact to impede the detection and treatment of depression, particularly among older clients (Klinkman, 1997; Meyers, 1996; Schulberg et al., 1996). Older clients are less likely than younger ones to voluntarily report affective symptoms of depression (Lyness et al., 1995). They are more likely to ascribe symptoms of depression to a physical illness (Knauper & Wittchen, 1994). Depressed older adults of various ethnic backgrounds are less likely to use specialty care and more likely to use the general health care system (Brown et al., 1995; Unützer et al., 1997).
- PST is a promising approach to treating depression in the context of home health care.
A recent randomized controlled trial in home care tested the effectiveness of home-delivered problem solving therapy (PST-HC) for depression in medically ill elderly over a 6-month period (Gellis, McGinty, Horowitz, Bruce, & Misener, 2007). Data suggested significant reductions in depression scores at post-baseline, and at 3 and 6 months, relative to the usual primary care condition. They also reported higher quality of life and improved problem solving ability. In a randomized trial of brief PST, the therapy was found to result in decreased symptoms of minor depression in older home care patients post-treatment, and the decrease was maintained over a 6-month period (Gellis, McGinty, Tierney, et al., 2007). Participants in the PST group were also more satisfied with treatment compared to the those in the control group.
Depression in Assisted Living
- Assisted-living residents appear to have significant rates of depression and depressive symptoms, yet their conditions are underdetected and undertreated.
- Depression may be associated with cognitive impairment, agitation, recent hospitalization, dependence on others for activities of daily living, psychosis, and social withdrawal.
A recent study attempted to obtain estimates of depression and related factors, and treatment rates of 196 ALF residents recruited from 22 facilities in Maryland (Watson et al., 2006). Most residents were female and widowed; a majority met criteria for dementia (68%), and 24% of the participants met the cutoff score for depression on the Cornell Scale for Depression in Dementia. Almost half (43%) of those depressed were receiving some type of antidepressant medication, while 57% of those depressed had not been referred to nor were receiving any psychiatric services.
Researchers examined a large data set of assisted living residents (N=2,078 residents aged 65 and older) in 193 assisted living facilities (Watson, Garrett, Sloane, Gruber-Baldini, & Zimmerman, 2003). They found relationships between depression and cognitive impairment, agitation, recent hospitalization, dependence on others for more than three activities of daily living, psychosis, and social withdrawal. At the 1-year follow-up study, 370 depressed residents had been transferred to a nursing home, and 250 residents with severe depressive symptoms had died.
- Multifaceted shared care appears to be a promising approach to treatment.
A randomized trial in Australia examined the effectiveness of a population based, multifaceted shared care intervention for late life depression in 220 depressed residential care residents in one large residential facility (Llwellyn-Jones et al., 2001). The intervention sought to provide depression related health education and activity programs for residents, increase the detection rate of depression by care staff, get elderly people to accept that depression is treatable, and provide accessible treatment programs in residential care. Follow-up results at the 9.5 month point showed that the experimental condition had resulted in reduced depressive scores compared to scores associated with the usual primary care control condition.
Depression in Long-term Care/Nursing Homes
- About 5% of older adults live in a long-term care facility. (Other prevalence data reported above.)
- A significant proportion of long-term care elderly with cognitive impairment and dementia have depression. Conversely, depression is a risk factor for dementia.
- Rapid screening, accurate diagnosis, and early treatment are likely to reduce symptoms of depression.
McCabe and colleagues (2006) studied the prevalence of depression among older people with cognitive impairment and found that 17.7% met criteria for a diagnosis of MDD, while 38.9% had clinically significant depressive symptoms. Individuals with moderate to severe cognitive impairment were more likely to present with MDD than were those with mild cognitive impairment or normal cognitive function. Depression is frequently a comorbid condition with dementia with estimates at 30% (Evers et al., 2002; Terri & Wagner, 1992), and studies indicate that depression is a risk factor for dementia (Alexopoulos, Meyers, Young, Mattis, & Kakuma, 1993; Lichtenberg & Mast, 2003).
In a study of outcomes of depression in 201 long-term care residents with dementia and depression, it was found that at 6 months post-admission, 15% of the original sample was still depressed, and at 12 months only 7.5% were depressed (Payne et al., 2002).
- Undetected, untreated, or inadequately treated depression may result in high rates of nursing home placement in patients with dementia, due to an increase in their functional disability.
A recent study focused on specific factors that might contribute to nursing home placement by examining the detection and course of coexisting dementia and depression (CDD) in elderly patients compared with patients with either disorder alone (Kales, Chen, Blow, Welsh, & Mellow, 2005). This study found lower rates of depression detection by treating (i.e., non-study) physicians in CDD patients. Only 35% of the CDD group were correctly diagnosed and received adequate treatment. The CDD group had significantly higher levels of functional impairment when compared to the dementia-only group. The CDD subjects used nursing home care at significantly higher rates.
- Many long-term care residents present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect).
- Comorbidity of anxiety and depression is most prevalent in more severely depressed and anxious nursing home patients.
Many long-term care residents present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect) (Gauthier, 2003). Smalbrugge and colleagues (2005) examined the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among 333 nursing home patients in the Netherlands. Using a diagnostic research interview, they estimated the prevalence of major depression at 17.1%, anxiety at 4.8%, and comorbid anxiety and depression at 5.1%. The prevalence of depressive disorders (both major and minor) was 22.2%, and that of anxiety was 9.9%. The researchers concluded that the comorbidity of anxiety and depression is most prevalent in more severely depressed and anxious nursing home patients.
- Research literature on interventions for depression in older adults residing in long-term care is sparse and deficient.
- Researchers recommend a combined approach to depression treatment including behavioral interventions and antidepressants. They suggest psychosocial intervention as an initial treatment step and the introduction of medication in more severe forms of depression. A few psychosocial interventions such as group and individual behavioral therapies show some potential but require further investigation.
A randomized trial compared an individual 8-week life review treatment with friendly visiting as the control on depressive symptoms in 201 nursing home residents (Haight, Michel, & Hendrix, 1998). Results demonstrated that the treatment group had reduced BDI scores compared to control participants at 1-year follow-up evaluations.
In a small pilot study, Hyer and colleagues (1990) compared the effectiveness of a 12-week group psychotherapy, in a cognitive behavioral format, to usual primary care in a sample of 22 residents. At post-treatment, depression scores decreased in the treatment group but not in the control group.
Teri and colleagues (1997) conducted a randomized controlled trial of two psychosocial interventions for depression in Alzheimer’s patients living with their caregivers in the community. Participants met diagnostic criteria for major or minor depression. Patient-caregiver dyads were randomly assigned to 1 of 4 conditions and assessed at pre-, post-, and 6-months follow-up intervals. Conditions included (1) behavior therapy-pleasant events (BT-PE), (2) behavior therapy-problem solving (BT-PS), (3) typical care control (TCC), and (4) wait-list control (WLC). They found that patients in both behavioral treatments showed significant improvement but not in the other two conditions. Caregivers in each behavioral condition also showed significant improvement in depressive symptomatology. In contrast, caregivers for patients in the other two conditions did not.
Researchers have recommended a combined approach to depression treatment including behavioral interventions and antidepressants (Lyketsos & Olin, 2002).
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Document Date: September 9, 2009
UPDATED SEPTEMBER 2014
Zvi D. Gellis, PhD, University of Pennsylvania
Bonnie L. Kenaley, PhD, Boise State University
Stanley G. McCracken, PhD, University of Chicago
Depressive Disorders in Older Adults
Overview of Aging Population
- In 2010, 40.3 million individuals were 65 years or older, representing 13% of the total population, with a rapid growth projected during the next two decades.
- Between 2000 and 2010, the male population aged 60 to 74 increased by 35.2%, narrowing the gender ratio gap.
- The elder racial minority groups are projected to increase with non-Hispanic whites increasing by 54% from 2012 to 2030 and 125% for racial and ethnic populations during the same period.
The 2010 Census Bureau found that 40.3 million individuals were 65 years or older, representing 13% of the total population, with a rapid growth projected during the next two decades (U.S. Department of Commerce, 2011). Elders between 60 and 64 years of age showed the largest percent increase in population (55.6%) since 2000 (U.S. Census Bureau, 2010). This age group grew at a faster rate (15.1%) than individuals under the age of 45 (U.S. Census Bureau, 2011) and is expected to rise to 72,091,915 in 2030 and 88,546,973 in 2050 (U.S. Department of Commerce, 2010). Examining age in five-year cohorts, the U.S. Department of Commerce (2010) found an increase in the elder population, except for those between the ages of 75 and 70 years. Interestingly, there was a 30.2% increase in the 90- to 94-year-old population in 2010 compared with the same age group in 2000 and a 29.5% increase in the 95- to 99-year-old population in 2010 compared with the same age group in 2000.
A remarkable change was found between 2000 and 2010 regarding the sex ratio of elders. Defined as the number of males per 100, the sex ratio gap narrowed due to a 35.2% increase in the male population aged 60 to 74 compared with their female counterparts’ increase of 29.2%. The racial composition of elders is diverse, which demands tailoring of access to and treatment of minority populations. In 2011, 21% of individuals age 65 years or older were members of racial or ethnic populations (U.S. Department of Health & Human Services, 2012). Of the elders included in the 2011 census, 9% were non-Hispanic African-Americans, 4% were non-Hispanic Asian or Pacific Islander and the categories of Native Alaskan or American Indian and biracial add a population of less than 1%. The estimates of older growth by racial groups are projected to increase with non-Hispanic whites increasing by 54% from 2012 to 2030 and 125% for racial and ethnic populations during the same period (U.S. Census Bureau, 2011). Added to this trend is the increasing proportion of African-American, Latino, and Asian-Americans (Areàn et al., 2005; Gelllis & Taguchi, 2003; Harada & Kim, 1995), who tend to have more obstacles than Caucasians in accessing mental health services.
Prevalence and Characteristics of Depression in Older Adults
- Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes.
- Estimates of major depression in large-scale community studies are generally low, ranging from 1% to 4.6%.
- For elders living in home health care settings, estimates for major depression range from 6.4% to 13.5%.
Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes. Estimates of clinically significant depressive symptoms range from 10% to 48% (Dozeman et al., 2010; Koenig, Meadors, Cohen, & Blazer, 1988; Peterson, Williams-Russo, Charlson, & Myers, 1996; Steffens et al., 2000; Williams-Russo, Sharrock, Mattis, Szatrowski, & Charlson, 1995). The prevalence rate for dysthymia is approximately 2%, although estimates for minor depression are higher, ranging from 4% to 50% (Buchtemann, Luppa, Branesfeld, & Riedel-Heller, 2012; Blazer, 2002; Beekman et al., 1995; Thota, Sipe, & Byard, 2012). Late-life depression is associated with increased risk of lifetime chronic depression (Murphy & Byrne, 2012).
Prevalence estimates of major depression in large-scale community studies are generally low, ranging from 1% to 4.6%. For elders living in home health care settings, estimates for major depression range from 6.4% to 13.5% and 27.5% for subthreshold depression (Bruce et al., 2002; Gellis, 2010; Shao, Peng, Bruce, & Bao, 2011). In fact, depression is twice as prevalent in home health care as in primary care; it is persistent, intermittent, and is associated with medical illness, pain, and disability (Brown, Kaiser, & Gellis, 2007; Lyness, King, Cos, Yoediono, & Coaine, 1999). Late-life depression is one of the most common psychiatric disorders to present in primary care and home health care settings (Bruce et al., 2002; Gellis & Kenaley, 2008; Gellis et al., 2007; Lyness et al., 1999; Reynolds & Kupfer, 1999). In fact, depression is the third most common reason for consultation with a primary care provider (Singleton, Bumpstead, O’Brien, Lee, & Melzer, 2001).
Elders with major depression in primary care are more likely to die than their counterparts without depression, as elders present their depression as somatic symptoms, causing delay in treatment (Gallo et al., 2013). However, patients with major depression in primary care using intervention practices were 24% less likely to have died compared with their non-depressed peers (Gallo et al., 2013). Estimates for rates of major depression in medically-ill older adults range from 10% to 12% (Fiske, Wetherell, & Gatz, 2009). Thirty-nine percent of elders residing in assisted living facilities have depression (Jang, Bergman, Schonfeld, & Molinari, 2006; McDermott, Gillespie, Nelson, Newman, & Shaw, 2012). In long-term care settings, prevalence rates for major depression may range from 5% to 54% (Blazer, 2002; McDougall, Matthews, Kvaal, Dewey, & Brayne, 2007; Morrell et al., 2011; Seitz, Purandare, & Conn, 2010; Singleton et al., 2001) and clinically significant depressive symptoms range from 14% to 82% (Hyer, Carpenter, Bishmann, & Wu, 2005; McDougall, Matthews, Kvaal, Dewey, & Brayne, 2007; Seitz et al., 2010). Depression is underdetected in long-term care facilities and, if detected, is inadequately treated (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001; Brown, Lapane, & Luisi, 2002). In fact, 28% of older adult residents with depression have received ineffective or no treatment at all (Morrell et al., 2011).
Recent research has shown significant racial or ethnic differences in prevalence rates for depression. A study examining the National Survey of American Life found lifetime major depressive disorder (MDD) prevalence estimates at 17.9% for non-Hispanic whites, 12.9% for Caribbean Blacks, and 10.4% for African-Americans, yet 12-month MDD estimates across groups were similar (Williams, et al., 2012). In a secondary data analysis of the National Survey of American Life among older adult Medicare recipients, depression diagnosis rates were estimated at 7.2% for Hispanics, 6.4% for non-Hispanic whites, 4.2% for African Americans, and 3.8% for others (Akincigil et al., 2012).
Steffens and colleagues (2009) found whites and Hispanics experience nearly three times the prevalence of depression compared with African Americans. Widowed, separated, or divorced elders experience higher prevalence rates of MDD (Chou & Cheung, 2013) than those who were married. As many as 15% of older Latinos, 12% of older Asian-Americans, and 10% of older African Americans meet criteria for minor depression (Arean & Alvarez, 2001). In contrast to Zalaquett and Stens’ study (2006) that found no gender differences in the manifestation of depressive symptoms, Teng, Yeh, Lee, Lin, and Lai’s study (2013) found that depression was seen more often in men than their female counterparts. However, a systematic review of the incidence of late-life depression in elders 70 years and older found that major depression was more often found in females (Büchtemann, Luppa, Bramesfeld, & Riedel-Heller, 2012).
Risk and Protective Factors for Late-Life Depression
- Significant life events—assuming a caregiver role; bereavement; living in a rural area; being single or divorced or a widow or widower; suffering chronic and multiple comorbid medical conditions; and polypharmacological use—are risk factors for depression.
- Protective factors include positive beliefs and attitudes, exhibiting a higher sense of mastery, greater religiosity, and more positive attitudes toward aging.
- Though depression is not a normal experience of growing older, older adults are at increased risk for experiencing this disorder.
The etiology of depression is often unclear and is fraught with multiple concurrent factors that increase an older adult’s chance of developing depressive symptoms. Such factors include the occurrence of significant life events, such as assuming a caregiver role and bereavement (Cole & Dendukuri, 2003; Magnil, Janmarker, Gunnarsson, & Björkelund, 2013; Montesó et al., 2012). In a study of rural dwelling elders, Montesó and colleagues (2013) found that both widowers and widows were at risk for experiencing depression, yet males were more vulnerable for depression than females. In a systematic review of risk factors for depression in community-dwelling elders that involved a qualitative and quantitative synthesis of the data, Cole and Dendukuri (2003) examined 20 studies and found that females were more at risk for depression compared with males. However, the risk for depression, considering gender, may change due to the situation.
Chronic medical conditions may contribute to the development and continuation of depressive symptoms and disorders. Insomnia, especially characterized by difficulty in initiating sleep and maintaining sleep, daytime sleepiness, and prior history of depression increase the risk for depression (Jaussent et al., 2011). Other medical conditions such as diabetes, cardiovascular disease, and arthritis increase the risk of late-life depression. Depressed elders are at a four-fold risk for diabetes and cardiovascular disease, especially those who experienced myocardial infarction, heart failure, or coronary artery bypass surgery; depressed elders with arthritis have a nine-fold risk of falls (Teng et al., 2013). Elders living in long-term homes who suffer from nervous system disorders are at an 11-fold risk of experiencing depression (Wang et al., 2012). In fact, elders with low functioning due to other medical conditions are at increased risk for depression (Montesó et al, 2012;Yang, Berman, Schonfeld, & Molinari, 2006). Additionally, the loss of ability to perform activities of daily living due to medical ailments also increases the risks for elders to experience late-life depression (Yang et al., 2006; Montesó et al., 2012), with men being more at risk compared with women (Montesó et al., 2012). The older adult’s perception of their health status also influences the risk for depression, with those who report a poor rating experiencing more depressive symptoms than those who have a more positive perception of their health status (Yang et al., 2006).
The aging process presents the occurrence of medical conditions which require pharmacological treatment; sometimes the use of several medications. A polypharmacological regimen in treating a medical and/or psychological disorder(s) increases the risk of depressive symptoms (Kao, Wang, Tzeng, Liang, & Ling, 2012), as well as increasing the risk of falling by six-fold (Teng et al., 2013). The use of sedatives and hypnotics is a strategy to treat insomnia and anxiety, often-occurring ailments in elders. However, while these drugs may resolve the adverse effects of the disorder(s), their side effects or interactions with other drugs may cause depressive symptoms (Magnil et al., 2013). Additionally, medical conditions may require ancillary devices which increase the risk of depression in elders by five-fold (Kao et al., 2012). Other risks for major and subthreshold depression include poor social supports, lack of engagement in leisure activities (Lee et al., 2013; Magnil et al., 2013), high stress levels (Lee et al., 2013), and low education (Teng et al., 2013). Elders with war-related experiences are at higher risk for depression compared with their peers lacking such stressful histories (Strauss, Dapp, Anders, von Renteln-Kruse, & Schmidt, 2011).
Protective factors that guard against the manifestation of depressive symptoms and disorders include having a positive attitude toward aging, practicing a religion, life satisfaction, and a sense of mastery (Hashe, Morrow-Howell, & Proctor, 2010; Jang et al., 2006). Elders residing in long-term care homes who are satisfied with their life are less likely to experience depression compared with those whose perceptions are less positive (Hashe et al., 2010). Elders who have positive beliefs and attitudes exhibit a higher sense of mastery, greater religiosity, and more positive attitudes toward aging, resulting in a decreased risk for depression (Jang et al., 2006). Additionally, instrumental and emotional support from family members as well as assistance from formal organizations improves the psychological well-being among older adults and moderates the association between functional disability and depression (Chao, 2012). In fact, concordance in the perception of financial, physical, caregiving, social, and environmental needs between community-dwelling elders and their formal or familial caregivers improves the elder’s quality of life and decreases the risk for major depression (Hourties, van Meijel, Deeg, & Beekman, 2012).
Comorbidity of Depression in Older Adults
- Comorbidity of depression with physical disorders is common and negatively influences the course of the depression and increases functional impairment, health costs, and use of health services.
- Common medical illnesses known to be associated with depression include cerebrovascular disease, heart disease, stroke, hypertension, diabetes, cancer, neurological conditions, and osteoarthritis.
Depressed elders often experience comorbid medical issues and functional disability (Alexopoulos et al., 1996; DaSilva, Scazufca, & Menezes, 2013; Dauphinot et al., 2012; Proctor et al., 2003), with 23.8% experiencing one or two medical conditions, and 27.7% manifesting three or four medical illnesses (Spangenbrg, Forkmann, Brahler, & Glaesmer, 2011). Medical conditions known to be associated with depression include heart disease, asthma, hypothyroidism, stroke, dementia, diabetes, cancer, chronic pain, and arthritis (Chou & Cheung, 2013; Gellis et al., 2012; Krauskopf, 2013; McCarthy et al., 2009). Adjusting for demographic factors, socioeconomic conditions, physical morbidities, and dementia, high functional disabilities are associated with major depression (DaSilva et al., 2013). Recent neurological and immunological studies have found that depressive symptoms may be linked to impaired late-life autonomic nerve or peripheral nervous system performance (Dauphinot et al., 2012), affecting heart rate, digestion, respiratory rate, salivation, perspiration, pupillary dilation, urination, sexual arousal, and ultimately causing immune deficiency.
Negative outcomes of comorbid medical conditions and associated depression include poor social support, impaired functional status, increased disability, and increased rates of mortality and suicide (Brown, Kaiser, & Gellis, 2007; Center for Disease Control and Prevention, 2013; Preyde & Brassard, 2011; Teng et al., 2013). In a national longitudinal study (Teng et al., 2013), older adults with chronic depression have a higher risk of mortality compared with those with less chronic conditions. The risk for mortality increased for older adult males with depression and cardiovascular conditions; the risk for mortality in older adult females increased with non-cardiovascular conditions. Depression associated with physical illness increases levels of functional disability (Gellis & Kang-Yi, 2012; Proctor et al., 2003), use of health services (Beekman, Deeg, Braam, Smit, & van Tilburg, 1997; Saravay, Pollack, Steinberg, Weinsched, & Habert, 1996), and health care costs (Callahan, Kesterson, & Tierney, 1997; Manning & Wells, 1992; Preyde & Brassard, 2011; Simon, VonKorff, & Barlow, 1995), particularly among older adults. It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996).
While elders only make up 13% of the population, they account for approximately 20% of all suicides and have a higher completion rate compared with their young counterparts (Center for Disease Control and Prevention, 2013; Hoyert, Kung, & Smith, 2005; Peaerson & Brown, 2000). In the U.S., suicide rates for males and females age 65 years and older were elevated with a ratio of 150 suicides per 100,000 between 2000 and 2010 (Lapierre et al., 2011). White males 85 years and older have the highest suicide completion rates (45 per 100,000) (Centers for Disease Control and Prevention, 2013). Social inequalities play a role in suicidal ideations and suicide in older adults, including financial strain and an annual income of less than $20,000 (Gilman et al., 2013). Additionally, elders who are divorced or separated, living alone, have previous psychiatric history, a previous suicide attempt, less than a high school diploma, a lack of social support, and suffer from comorbid medical conditions have an increased risk for suicidal ideations or suicide (Gilman et al., 2103; Peters, Kochanek, & Murphy, 1998; Wiktorsson, Runeson, Skoog, Ostling, and Waem, 2010). Retrospective studies identified that greater than 70% of late-life suicide victims had contact with their primary care provider within 3 to 6 months prior to their death (Conwell, Olsen, Caine, & Flannery, 1991; Conwell, 1994; Diekstra & van Egmond, 1989; Frierson, 1991; Tadros & Salib, 2007; Uncapher & Areán, 2000). Elders with late-life depression are more likely to present somatic symptoms during their visits to their primary care physicians compared with their younger counterparts who present with more psychiatric symptoms (Tadros & Salib, 2007), which decreases the likelihood of detecting depressive symptoms and initiating treatment. Additionally, the majority of older patients who experience late-onset and untreated depressive symptoms usually suffer high rates of comorbid illness and/or fears of pain or dependency on others (Duberstein, 1995).
Beliefs and perceptions by health professionals also contribute to not detecting depression and suicidal ideations, hence increasing the risk for suicidal attempts and completions. In a study of 159 staff members at four long-term care facilities, Tracey and Heck (2013) compared the beliefs of depression as a normal aging process between paraprofessional staff (certified nursing assistants) and professional staff (social workers, licensed practical nurses, registered nurses, and mental health counselors) working at long-term care facilities. Interestingly, professional staff viewed depression as a normal part of aging and that older adults are less likely to commit suicide compared with paraprofessional staff who believed that depression and suicide were not normal behaviors in elders (Tracey & Heck, 2013). These findings indicate the need for training for those working with the older adult population, involving normal geriatric development, methods for identifying depressive symptoms, and prevention and treatment for depression in different elder care settings.
Depression Screening
- The goal of screening is early identification and, thus, prevention through early intervention.
- Key criteria to be used by agency personnel to justify mental health screening for late-life depression include the following:
- Is the national incidence of depressive disorders in the older adult population high enough to justify the cost of screening in an agency?
- Does the problem have a significant effect on the quality of life of the older adult?
- Depression symptomatology varies significantly for each elder.
- Is effective treatment available?
- Are valid and cost-effective screening instruments available?
- Are the adverse effects (if any) of the screening tests acceptable to social workers and older adult clients?
A number of standardized self-report rating scales for assessing the presence and severity of depressive symptoms include the Center for Epidemiological Studies-Depression Scale (CESD), Geriatric Depression Scale (GDS), Zung Self-Rating Depression Scale, Beck Depression Inventory (BDI-II), the Patient Health Questionnaire-9 (PHQ-9), and clinician-interview instruments, including the Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS) and the Cornell Scale for Depression in Dementia (CSDD). All of these measures are frequently used in long-term care settings (see citation and download information in Table 1 in this chapter's resource document). Older adults are not averse to screening for depression, outside of the time and effort required to complete a short interview or form, if the need for the screening is explained clearly and the screening is conducted in an empathetic manner (Gellis, 2009; Gellis & Kenaley, 2008: Gellis & Taguchi, 2003).
- For DSM diagnosis:
- Structured Clinical Interview for DSM-5 (SCID)
- Mini-International Neuropsychiatric Interview (MINI) is available in several languages. Register and download the instrument free at: https://www.medical-outcomes.com/indexSSL.htm.
- Steps in screening:
- Obtain the person’s agreement to be screened.
- Explain the purpose for the screening.
- Administer and score the screening tool per the instructions.
- If the screen is positive, make initial treatment referrals for further diagnostic assessment to the older person’s primary care physician for possible psychotherapy and antidepressant medication.
- The social worker is in a unique position to:
- Identify resources if financial barriers exist.
- Address stigma through psychoeducation.
- Encourage client follow-through with the referral.
Evidence-Based Treatment
Pharmacological Interventions
- Antidepressants are widely used and are safe and effective for the treatment of moderate to severe depression in older adults. All antidepressants are equally effective, though the most widely studied are tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). Medically-ill older adults have fewer adverse effects with SSRIs, which has led them to be more widely prescribed in primary care settings.
- As older adults are prescribed more medications for other medical diseases, the likelihood of self-medication, multiple drug use, drug interactions, and unpleasant side effects increases.
Based on several literature reviews of pharmacologic treatment for late-life depression, antidepressants are reported as a safe and first-line treatment for depressed older adults (Barkin, Schwer, & Barkin, 2000; Mamdani, Parikh, Austin, & Upshur, 2000; Chelmali, Chahine, & Fricchione, 2009; Salzman, Wong, & Wright, 2002; Solai, Mulsant, & Pollock, 2001). Almost all antidepressant medications are equally effective for treating major depression (Blazer, Hybel, Simensick, & Harbin, 2000; Salzman et al., 2002).
During the past two decades, over 30 randomized placebo controlled clinical trials as well as many comparative trials (Das Gupta, 1998; Salzman et al., 2002) have been conducted that have documented the efficacy and safety of tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitor(SSRI)antidepressant medications for older adults with depression. Dolder, Nelson, and Stump (2010) conducted a review of 14 studies examining the efficacy and safety of two more recently developed antidepressants, escitalopram, an SSRI and duloxetine, a serotonin-norephinephrine reuptake inhibitor (SNRI). In contrast with those who received escitalopram, duloxetine-treated patients experienced improvement in their depressive symptoms. Both medications were generally well-tolerated; however the adverse side effects experienced included constipation and dry mouth, two pharmacological side effects common in older adults. Naturalistic studies have shown that medically ill older adults have more adverse effects to TCAs than to SSRIs (Cole, Elie, McCusker, Bellavance, & Mansour, 2001; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001), and the use of SSRIs in primary care has become more common (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003).
As older adults are prescribed medications for mental health conditions and comorbid illnesses, the likelihood of self-medication, multiple drug use, drug-drug interactions, and unpleasant side effects increases. Common side effects of SSRIs include nausea, constipation/diarrhea, weight changes, sexual dysfunction, gastrointestinal bleeding, dry mouth, and hyponatremia (Dolder, Nelson, and Stump, 2010; Chemali et al., 2009). The antidepressant dose for older adult patients is “generally one-third to one-half of that recommended for a younger adult patient because of anticipated effects of aging on the pharmacodynamic effects of antidepressants and on pharmacokinetic parameters including drug distribution, metabolism, and elimination” (Ellison Kyomen, & Harper, 2012, p. 2009). Non-adherence to medication, especially antidepressants by older adults with major depression, is a major concern in treatment management (Grenard et al., 2011). In fact, between 24% and 28% of older adults are non-adherent in taking their medications (Keaton et al., 2009). For older patients, initial partial response of antidepressants may take up to 6 to 8 weeks, although subjective sense of improvement earlier in treatment may occur and suggests the likelihood of continued benefits (Ellison et al., 2009).
Biological Interventions
During the past decade several advances have been made in the use of biological treatment modalities for late-life depression, especially for the severely depressed elder. In a review of 22 studies (van Schaik et al., 2012), including three randomized clinical trials, continuation or maintenance electroconvulsive therapy (ECT) proved to be efficacious, safe, and well-tolerated by clients age 55 years or older. Considering the side effects of ECT, high-dose right side unilateral (RUL) electrode placement brief pulse ECT results in milder cognitive side-effects, yet has equal efficacy compared with bilateral electrode placement ECT, and greater efficacy compared with lower doses of RUL ECT (Alexopoulos & Kelly, 2009). Approved by the U.S. Food and Drug Administration in 2005, vagus nerve stimulation plus treatment as usual has shown efficacy in treating resistant depression when compared with treatment as usual (Alexopoulos & Kelly, 2009). Another new and efficacious advancement is the use of deep brain stimulation, which stimulates portions of the basal ganglia resulting in reduction of symptoms or remission of depression. These advancements have shown efficacy for elders with persistent and major depressive symptoms and the possibility for increasing their quality of life and functionality.
Psychosocial Interventions
- Late-life depression is pervasive, debilitating, and intimately linked with the presence and development of medical disorders. Patients with depression go undetected or untreated despite the patient’s ongoing involvement with a primary care clinician.
- Older adults often prefer to receive treatment for depression, along with care for medical conditions, in primary care settings.
- Psychosocial interventions have been demonstrated to be effective among older adults, particularly those who reject medication because of unpleasant side effects or who are coping with low social support or stressful situations.
- Psychosocial interventions alone are effective with older populations including minorities. Cognitive therapies, including Problem-solving Therapy, are particularly promising among older men and women of diverse ethnic backgrounds.
The majority of primary care patients prefer counseling over medication, which should be kept in mind since patient attitudes and preference affects acceptance of and adherence to the prescribed treatment for depression. Late-life depression is pervasive and has debilitating psychological and medical effects and costs (Ellison et al., 2012) and is likely to go undetected and untreated (Brown, Lapane, & Luisi, 2002; Duberstein, 1995; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). More than one-third of suicide victims have at least one prior suicide attempt, which increases the number of attempts and completed suicides (Rihmer & Gonda, 2011). Elders who attempt suicide are often more frail, more isolated, more likely to have a plan, and determined to complete the suicidal attempt compared with younger suicidal individuals (Administration on Aging, 2012). Elders are more serious in their attempts, with firearms being the most commons means to commit suicide (67%), followed by poisoning (14%), and suffocation (12%) (Administration on Aging, 2012). The lethality of late-life suicide suggests that suicide prevention and interventions must be aggressive (Administration on Aging, 2012). Collaborative care models in primary care (e.g., IMPACT) have demonstrated greater improvement in depression symptoms and reduced suicidal ideation as compared with primary care physician treatment alone (Katon et al., 2010). A randomized clinical trial (Gallo, 2013) examining the efficacy of another suicidal intervention, PROSPECT– Prevention of Suicide In Primary Care Elderly: Collaborative Trial, found that patients with major depression who received the intervention were 24% less likely to die than were the patients with depression who received usual care treatment, indicating that a prevention model is effective in reducing suicidality in elders. The Administration on Aging (2012) suggests the suicide prevention guidelines listed in this chapter's resource document.
Manualized depression interventions that have been modified for older adults and have met evidence-based guidelines include cognitive-behavioral therapy (CBT), problem-solving therapy (PST), behavioral therapy, cognitive bibliotherapy, brief psychodynamic therapy, and life review therapy (Dickens et al., 2013). Evidence-based therapies such as CBT, PST, and interpersonal therapy (IPT) are effective intervention alternatives or adjuncts to medication treatment (Dickens et al., 2013; Gath & Mynors-Wallis, 1997; Gellis et al., 2007; Gellis et al., 2008; Gellis & Bruce, 2010; Hegel, Barrett, Cornell, & Oxman, 2002; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Jacobson & Hollon, 1996; Pen, Huan, Chen, & Lu, 2009; DeRubeis, Gelfand, Tang, & Simons, 1999; Schulberg, Pilkonis, & Houck, 1998). Psychosocial interventions have been demonstrated to be effective among older adults, particularly the 24% to 28% who are non-adherent in taking their medication because of unpleasant side effects or who are coping with low social support or stressful situations (Choi & Morrow-Howell, 2007; Gellis, 2006; Gellis et al., 2012; Keaton et al., 2009).
There is evidence that psychosocial interventions alone are effective with older populations, including minorities (Coulehan, Schulberg, Block, Madonia, & Rodriguez, 1997; Mossey, Knott, Higgins, & Talerico, 1996; Munoz et al., 1995). Cognitive therapies, including PST, are particularly promising (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; McCusker, Cole, Keller, Bellavance, & Berard, 1998; Nezu, 2004; Robinson et al., 1995) among older men and women of diverse ethnic backgrounds (Gil et al., 1996). Patient attitudes and preference for treatment type has been shown to affect acceptance of and adherence to the prescribed depression treatment (Schulberg, Magruder, & deGruy, 1996), and the majority of primary care patients prefer counseling over medication (Brody, Khaliq, & Thompson, 1997; Landreville et al., 2001).
Literature reviews on the effect of CBT on late-life depression noted that CBT was at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy (Areán & Cook, 2002; Cuijpers, van Straten, & Smit, 2006; Laidlaw, 2001; Pinquart & Soerensen, 2001; Zalaquett & Stens, 2006). Hofmann and colleagues’ 2012 review of a representative sample of 106 recent meta-analyses revealed that CBT was more effective than waiting list control groups, but equally effective in comparison to reminiscence therapy, psychodynamic therapy, and interpersonal therapy. Considering long-term effects of CBT for elders with late-life depression, one meta-analysis revealed that treatment gains of CBT were maintained at the 11-month follow-up. However, overall, the meta-analyses indicated minimal long-term effect and the interactions of effects of CBT with antidepressant therapy (Hofmann et al., 2012), contradicting previous studies (Areán, Gum, & McCulloch, 2003). The later study’s sample was limited to low income elders, though, a factor that may have contributed to more successful outcomes. Factors that contribute to success of CBT therapy in reducing or ameliorating late-life depression include the elder’s ability to be open to new experiences, be less negatively affected by past stressors, be accountable for stressful life situations, and be open to seek emotional support when symptomatic (Marquett et al., 2013).
In a study of older low-income primary care patients with MDD, Spanish-speaking and English-speaking patients responded equally well to CBT alone versus case management (Miranda, Azocar, & Organista, 2003). Moreover, CBT and supplemental case management were associated with greater improvement in symptoms and functioning than CBT alone for Spanish speakers, but CBT was less effective for those whose first-language was English. Even so, a dearth of studies exists to inform social workers about the use of CBT and associated strategies for successful implementation of CBT among diverse populations, especially older gay populations.
Problem-solving Therapy (PST)
- PST has been found to be effective in frail, homebound, medically-ill individuals, and a short (6-week) course of treatment is as effective as medication in individuals with major and minor depression.
PST interventions for depression by non-medical mental health practitioners have demonstrated effectiveness for homebound, frail, medically-ill populations (Gellis & Bruce, 2010; Gellis, Kenaley, & Ten Have, 2014; Gellis, et al., 2007; Gellis et al., 2012; Mynors-Wallis, Gath, Davies, Gray, & Barbour, 1997). Adjunct written educational materials for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Some studies have found that six sessions of PST are as effective as pharmacotherapy among ambulatory primary care patients with minor and major depression (Hegel et al., 2002; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995).
Cognitive-behavioral Therapy (CBT)
- CBT (either individual or group) is at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy.
- Combined case management and CBT may have more efficacy than CBT alone for low-income and/or certain minority group member.
Interpersonal Therapy (IPT)
- IPT, another evidence-based intervention for late-life depression, focuses on relationships and conflicts with family and friends. Its purpose is to improve communication in those relationships, and develop or enhance the social support network.
IPT is another evidence-based intervention for late-life depression that focuses on the depressed person’s relationships and conflicts with family and friends (Hinrichsen, 1999). The overall purpose is to improve communication in those relationships and to develop or enhance the social support network of the identified depressed patient (Weissman & Markowitz, 1994). Several meta-analytic reviews noted findings of the efficacy of IPT for depression (de Melo, de Jesus, Bacaltchuk, Verdeli, & Neugebauer, 2005; Parker, Parker, Brotchie, & Stuart, 2006; Thase et al., 1997; Weston & Morrison, 2001).
Other Therapies and Interventions
- Adjunct written educational materials for clients and family members improve medication adherence and clinical outcomes.
- Treatment protocols for late-life depression are typically time-limited (6-20 sessions) psychotherapeutic interventions.
- The goal of brief interventions is to treat the problem, specifically, changing the behavior of individuals who are experiencing mental health problems in later life. These psychosocial interventions include assessment and direct feedback, contracting and goal setting, cognitive and behavioral techniques, and the use of educational and other written materials.
- There is unfortunately less available evidence on culturally appropriate mental health treatments for older adults.
Educational materials written for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Interventions for depression generally range from 6 to 20 sessions, each lasting about an hour (Gellis et al., 2007; Hegel et al., 2002; Nezu, 2004; Nezu & Nezu, 2001). Review the list of interventions for approaching late-life depression in this chapter's resource document.
To address individual and geographic barriers and reduce health costs, telehealth applications (defined as remote patient monitoring, internet, audio, and video technologies) to provide medical and mental health services have been used for the past five decades (van den Berg, Schumann, Kraft, & Hoffmann, 2012). Depression treatment has been shown to be effective when integrated with telehealth technology among depressed older adults with comorbid diseases (Gellis & Kang-Yi, 2012; van den Berg et al., 2012). A recent study examining the collaboration of CBT and telehealth revealed favorable findings in decreasing insomnia and reducing depression (Lichstein, 2013). However, further investigation with a more robust design is warranted to confirm the effectiveness of CBT with telehealth in medically-ill elders. A recent randomized trial of the “Tele-HEART” program providing remote patient monitoring of cardiac disease symptoms and integrated depression care found a 50% reduction in depression symptoms over a 3-month period and cost reductions in emergency department use over a 12-month period (Gellis et al., 2012).
Past research examined the use of internet and telephone therapy to provide depression treatment with positive outcomes (Speck et al., 2008). Since telephone therapy is generally not covered by reimbursement models, cost-benefits must be taken into consideration. Kiosses and colleagues (2010) examined PATH depression intervention compared with usual care for cognitively-impaired depressed older adults and found that depression significantly decreased over 12 weeks compared with usual care. In another randomized control trial with 138 older adults aged 50 years, participants received either problem solving treatment and behavioral activation (PEARLS) or usual care with reported improvements in depressive symptomatology for the intervention (Ciechanowski et al., 2004). The Healthy IDEAS study, examining the impact of an intervention for depression delivered by case managers in community-based agencies to 94 high-risk, diverse older adults, found that, at 6 months, participants significantly improved their knowledge of how to obtain help for their depression and reported increased activity and reduced pain (Quijano et al., 2007).
While life-review therapy has been shown to be efficacious in treating elders with depression, the use of new media and e-mental health has further advanced life-review therapy. Preschla and colleagues (2014) conducted a six week life-review therapy in a face-to-face setting with touch screen computer supplements from the e-mental health Butler system, consisting of exercise instructions (mindfulness, relaxation, and guided exercises) and autobiographical retrieval practice to assist positive valuated life episodes. The study found that this innovative intervention decreased depressive symptoms, and increased self-esteem and sense of well-being (Preschla et al., 2014).
Cost of Depression
The detrimental effects of late-life depression both for individuals and society include enormous costs due to use of health care services and an increased need for nursing care (Lavretsky and Kumar, 2002; Lyness et al., 2009; Blazer, 2003; Beekman et al., 1997; Luppa et al., 2007). In fact, the cost incurred by those who are depressed is significant with the total ambulatory and inpatient costs for depressed older adults being 47% to 51% higher compared with their counterparts without depression after adjusting for chronic medical illness (Katon, 2003). Average six-month total costs were $1,045 to $1,700 higher for the depressed elders compared with the non-depressed elders (Katon, 2003). In a randomized control study, Luppa et al. (2010) found elders with depression had higher pharmaceutical costs, medical supplies costs, and home care costs compared with elders without depression. Additionally, the study found the annual direct costs of elders with depressive symptomatology exceeded the total direct costs of non-depressed elders. Due to the decrease in functionality and co-occurring medical illnesses, depression in late-life is associated with use of health services (Beekman, Deeg, Braam, Smit, & van Tilburg, 1997; Saravay, et al., 1996) and health care costs (Callahan, et al., 1997; Simon et al., 1995; Unützer et al., 1997). It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996).
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Document Date: September 9, 2009
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Document Date: September 9, 2009
Mrs. D. is a 77-year-old woman living alone in own apartment who lost her husband 2 years ago. About 3 years a ago, she was diagnosed with cardiac disease. Her daughter/son (Pat) decided to contact the primary physician’s office for the following reasons.
During the past 2 months:
- Mrs. D. has complained of not sleeping well, loss of appetite, and back pain.
- She is not remembering things as well as she used to.
- She has difficulty concentrating and making decisions.
- She worries about paying bills.
- She has stopped playing cards.
- She is no longer interested in seeing friends or going out.
- She has related thinking that things would be better if she were not around, “not a burden to my daughter,” but is not suicidal.
Activity #1. Class Discussion
- What information do you collect?
- What are the risk factors?
- What are the symptoms?
- What do you say to Mrs. D. and her daughter?
- What is your assessment and treatment plan?
Activity #2. Role Plays
- Divide students into groups of three.
- Ask students to go on-line and download the PHQ-9.
- Ask the students to take the following roles:
- Ms. D.
- Pat (daughter)
- Social worker
- If a particular task only requires two people, the third person becomes an observer and after the task provides the following discussion and question feedback to the other participants:
- What did you do that you liked?
- What would you do differently next time?
- This is what you did that I liked…”
- This is what you might consider doing differently next time…”
(If time allows—and if appropriate for the particular students, you may ask the client in the role play to provide feedback to the social worker. This is what you did that I liked… This is how I felt when you... This is what you might try next time…)
- Remind students that the case example only provides an outline, they are to improvise additional details as needed. (Be kind to one another. The goal is not to “stump the chump” but to have an opportunity to practice using skills with an older adult and family member.)
- Depending on the level and experience of the students, it may be necessary to model the tasks before doing the role plays.
- Task #1: Social worker role plays an initial review of depression with Mrs. D. (Third student observes.) Use intervention questions for approaching late-life depression, for example:
- How are things at home?
- How have you been coping?
- Have you had any stress lately?
- Have you experienced any losses?
- How are you handling it?
End role play; observer provides feedback.
- Task #2: Rotate roles. Social worker introduces the screening and conducts a PHQ-9 interview with Mrs. D. [Download from http://www.agencymeddirectors.wa.gov/Files/depressoverview.pdf]
- Obtain the person’s agreement to be screened.
- Explain the purpose for the screening.
- Administer and score the PHQ-9 as instructions direct.
- Task #3: Rotate roles. Social worker discusses his/her concerns and makes initial treatment referrals for further diagnostic assessment to Mrs. D’s primary care physician for possible psychotherapy and antidepressant medication.
- Discuss your concerns with Mrs. D and Pat.
- You can say:
- Depression is very common.
- Depression is a medical condition.
- Depression is very treatable.
- Task #4 (optional): Ask one student to take the role of the social worker and the other to take the role of the primary care physician (PCP). Social worker presents his/her concerns and the results of the PHQ-9 to the PCP. (Remind students that the PCPs time is quite limited and that they will need to be concise and focused in their presentation of Mrs. D and her situation.)
- For example: I am concerned that Mrs. D may be depressed, and I think that she would benefit from further diagnostic assessment and treatment. Here is what I have seen that leads to my concern… [present a brief overview of her situation and the results of the PHQ-9].
Document Date: September 9, 2009
Download this PowerPoint for Chapter 3 of the Mental Health Resource Review.
Document Date: September 9, 2009
Stanley G. McCracken, PhD, University of Chicago
Zvi D. Gellis, PhD, University of Pennsylvania.
Chapter 4: Schizophrenia in Older Adults
Profile
- Purpose: To teach master’s-level direct practice social work students about schizophrenia in older adults.
- Audience: Masters-level social work students.
- Audience Size: Maximum 40.
Content
- Core Values
- To recognize and treat older adults as people first.
- To understand that older adults have goals and desires just like younger people, which may include independent living, meaningful and enjoyable activities, and mature relationships, and that they also have the capacity to learn, grow, and achieve these goals.
- To foster and promote the understanding that older adults deserve courtesy, respect, and dignity in all interactions.
- To provide a safe, caring environment in which to live.
- To advocate for evidence-based interventions and services that are sensitive to diversity.
- To attempt to change the environment to meet the resident’s needs.
- To make every effort to support attempts to build and maintain skills and promote independence.
- Informational Competencies.At the end of this module, students will know:
- That the prevalence of schizophrenia varies greatly according to setting.
- That psychotic symptoms can be produced by a number of different conditions.
- The differences between early, late, and very late onset schizophrenia.
- That early onset schizophrenia has a number of different patterns for the course of the illness over time.
- That antipsychotic medication is effective in treating schizophrenia, but that no one drug or category of medication has proven more effective than any other.
- That conventional and atypical antipsychotic drugs have different profiles of side effects and risks.
- That there is less research on non-pharmacological treatments for schizophrenia than there is for pharmacological interventions.
- That most non-pharmacological interventions used in treatment of older adults with schizophrenia are extensions of practices used in younger individuals.
- That cognitive behavioral therapy, social skills training, and individual placement and support all have some evidence supporting their effectiveness with older adults with schizophrenia.
Time Needed:
45-80 minutes, depending on class size and time spent on exercise.
Training Format:
Didactic lecture, exercises.
Equipment
Chalkboard, flipchart, or dry erase board with markers.
LCD projector & laptop computer.
Slides
PowerPoint slides
Literature Review
Review of the literature
[Note about language: In this module we will use the language recommended by the International Late-Onset Schizophrenia Group (Howard, Rabins, Seeman, Jeste, & the International Late Onset Schizophrenia Group, 2000) in referring to the age of onset of symptoms of schizophrenia: Earlier Onset Schizophrenia (EOS), prior to age 40; Late Onset Schizophrenia (LOS), onset from 40 to 60; Very Late Onset Schizophrenia (or Schizophrenia-like Psychosis, VLOS), onset after age 60.]
Epidemiology of Psychotic Symptoms in Older Adults
- The prevalence of psychotic disorders, specifically schizophrenia and schizophreniform disorder, is low among adults over 65. However, the prevalence of psychotic symptoms is high.
The prevalence of psychotic disorders among the elderly ranges from 0.2% to 4.75% in community samples, to 8% to 10% in geropsychiatry units and nursing homes (Zayas & Grossberg, 1998). The epidemiologic catchment area (ECA) study data showed a 0.2% point prevalence and 0.3% lifetime prevalence among adults over 65 (Keith, Regier, & Rae, 1991). Note that the ECA study did not include individuals with onset of symptoms after 45. More recent estimates place the true prevalence of schizophrenia at about 1% among older adults; stated another way, apparently 13.6% of people with schizophrenia are 65 or older (Cohen, 2003). However, the prevalence of psychotic symptoms varies among different populations and settings. Ostling and Skoog (2002) found that 10.1% of their sample of community-dwelling non-demented adults over 85 experienced psychotic symptoms, most of which were associated with depression, disability in daily life, and visual deficits. Psychotic symptoms among individuals with dementias can be over 60% (Zayas & Grossberg, 1998).
- Psychotic symptoms in the elderly are more often associated with the presence and treatment of medical conditions, dementia, and other organic changes, and mood disorders than with psychotic disorders.
Psychotic symptoms also can be produced by a number of different medical conditions and their treatment: e.g., delirium; sensory impairments; drugs and medications; medical and surgical procedures; and neurological, infectious, metabolic, and endocrine disorders (Desai & Grossberg, 2003). Even in a specialty geropsychiatry clinic, the majority of older adults presenting with psychotic symptoms are diagnosed with dementia, major depression, delirium, and organic psychoses related to medical conditions and treatment (Holroyd & Laurie, 1999).
- When an older adult experiences psychotic symptoms, perform a differential diagnosis to identify the reason for symptoms and to rule out/identify medical and pharmacological precipitants of these symptoms.
- Determining the etiology of psychotic symptoms in elderly individuals (see decision tree below). A number of the steps involve medical determinations that must involve a physician to determine etiology of the psychotic symptoms.
- Take a thorough history to determine whether the individual has experienced psychotic or other psychiatric symptoms, has had a current or prior psychiatric diagnosis or treatment, or has a family history of psychiatric problems (e.g., psychotic or mood disorders, suicide, dementia). Take history from the individual and one other person who is quite familiar with him or her.
- The initial purpose of assessment: determine nature of symptoms, when they started and relationship with any stressors, and the degree of impairment and distress that they are causing.
- Gather information on use of prescribed medications, alcohol and other non-medical drugs, over-the-counter drugs, and herbal preparations.
Cognitive impairment is associated with schizophrenia; however, the progression of cognitive decline in an aging individual with schizophrenia parallels the decline seen in normal aging. Significant cognitive decline should raise the index of suspicion about the presence of dementia, which may be comorbid with another psychiatric disorder. Recent changes in orientation, awareness of the environment, or ability to attend indicates the possibility of delirium (Desai & Grossberg, 2003).
Older Adults with Early Onset Schizophrenia
- Two conflicting historical views of EOS: 1) schizophrenia has a course that is chronic and, if not deteriorating, is stable and usually nonremitting; 2) positive symptoms (such as hallucinations and delusions) “burn out” over time and are replaced by increasing negative symptoms (such as reduced affective experience and expression and reduced verbal output).
- Research has found a wide variety of outcomes among individuals with EOS:
- A substantial proportion of individuals recover over time.
Harding (2003) reviewed 10 long-term (>20 years) longitudinal studies looking at recovery from schizophrenia over time. From the methods reported in these studies, it appears likely that the majority of the subjects in the studies would meet DSM-IV criteria for schizophrenia. The rate of recovery or significantly improvement ranged from 46 to 84% for clinical recovery and 21 to 77% for social recovery; thus, there is considerable variability in the rate of recovery, particularly for social/functional recovery. Findings from these 10 long-term follow-up studies challenge the notion that schizophrenia has a chronic, deteriorating course with little hope of recovery.
- There is a wide variety of symptom patterns among individuals with EOS, much of which depends on whether the sample was from the community or institutional settings.
- Data suggest that positive symptoms either decrease or remain steady over time and that negative symptoms may increase over time.
- Symptoms of verbal disconnections (disorganized speech) decrease over time, while symptoms of verbal underproductivity (alogia) increase over time. This implies that positive symptoms do not necessarily decrease over time—individuals just may no longer talk about these symptoms.
Studies of individuals with chronic symptoms or who require hospitalization due to exacerbation of symptoms have shown that positive symptoms of schizophrenia continue throughout life (Davidson et al., 1995; Harvey et al., 1998). Davidson and colleagues (1995) found a linear decrease in severity of positive symptoms from ages 25 to 95, but individuals over 65 years old continued to experience significant psychotic symptoms. The researchers also found an age-related increase in severity of negative symptoms and cognitive impairment, and a positive correlation between negative symptoms and cognitive impairment. Harvey et al. (1998) found that cognitive impairment was a stronger predictor of adaptive functioning than either positive or negative symptoms across individuals from nursing homes, long-term hospital settings, and the community; and this was true across all levels of severity of the illness. Data from community-dwelling older adults with schizophrenia suggest that there are a number of individuals who have significant levels of positive symptoms that are stable over time (Harvey, 2005).
- Cognitive impairment. Some studies show abnormal cognitive decline, whereas others show rates of decline associated with normal aging. Impaired social functioning and adaptive functioning are strongly associated with cognitive impairment, weakly associated with negative symptoms, and not associated with positive symptoms.
Studies showing cognitive decline have mostly been conducted in individuals over 65 with a chronic course of institutionalization and living in hospitals or nursing homes at the time of the investigations. Data indicating less evidence of cognitive decline (i.e., no more than would be associated with benign aging) have typically included younger, community-dwelling individuals with no evidence of chronic institutional stays and a better lifetime course of the illness (Harvey, 2005; Kurtz, 2005). Deficits in social and adaptive functioning are most strongly associated with cognitive deficits, only weakly associated with negative symptoms, and not associated with positive symptoms; furthermore, functional deficits tend to be preceded by deficits in cognition (Friedman et al., 2002; Harvey, 2005).
- One should expect a large cohort effects among older adults with schizophrenia. Each successive 10-year age cohort is more likely than their predecessor to have been treated with antipsychotic medication early in the course of their illness and more likely to have received atypical antipsychotic medication. The effect of this remains to be seen.
Late Onset and Very Late Onset Schizophrenia
- Research in this area is limited by the fact that, in the absence of treatment records, it is difficult to reliably determine the age of onset of symptoms of schizophrenia. Common unawareness of the illness along with memory impairments make retrospective judgments about the timing of symptom onset suspect.
- There also are a number of terminology problems when examining the literature.
The DSM-III prohibited a diagnosis of schizophrenia if the onset of symptoms was after age 45, and DSM-III-R provided a specifier to be used for onset after 44 (American Psychiatric Association [APA], 1980, 1987). Estimates are that 15-20% of individuals with schizophrenia have onset after age 44 (Folsom et al., 2006). Thus, the vast majority of older adult clients with schizophrenia will be among those with EOS. The term paraphrenia (experiencing hallucinations and delusions in the absence of functional deterioration or disturbance of affective response, and showing abnormal pre-morbid personality and social functioning; predominantly found in women) was included in the ninth edition of the International Classification of Diseases (ICD-9, 1980) (Howard et al., 2000). Neither the current edition of the ICD (ICD-10) nor that of the DSM (DSM-IV-TR) provides a separate code for late onset schizophrenia (World Health Organization [WHO], 1992; APA, 2000).
- Compared with EOS, later onset is characterized by:
- Greater prevalence of visual, tactile, and olfactory hallucinations; persecutory, partition, reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations.
- Lower prevalence of formal thought disorder and affective flattening or blunting.
- Risk factors: lower familial prevalence, female gender, cognitive impairment, and possibly sensory impairment.
Later onset is characterized by greater prevalence of visual, tactile, and olfactory hallucinations; persecutory, partition (belief that people, animals, materials or radiation can pass through a structure that would normally constitute a barrier), reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations. There also is a lower prevalence of formal thought disorder and affective flattening or blunting. Both formal thought disorder and negative symptoms are very rare in onset after 60 (Almeida, Howard, Levy, & David, 1995; Howard, 2001; Howard, et al., 2000; Palmer, McClure, & Jeste, 2001). Individuals with LOS and particularly VLOS appear to have a reduced prevalence of schizophrenia among family members, compared with individuals with EOS (Howard, 2001). Other risk factors for later onset schizophrenia include female gender, cognitive impairment, and possibly sensory impairment (Wynn Owen, & Castle, 1999).
Treatment of Schizophrenia in Older Adults
Pharmacological Treatment
- Overall, the literature suggests the following:
- Antipsychotic medication is effective in reducing psychotic symptoms in older adults with schizophrenia.
- Apparently, no drug or category of drugs is any more effective than any other.
- Adverse effects differ between the typical and atypical medications with typical medication having increased extrapyramidal symptoms (EPS), particularly tardive dyskinesia in older adults, and atypical medication having increased risk of elevated glucose and tri-glycerides; however, risk of death is not higher for users of atypical antipsychotic medications than for users of ones.
- Doses may need to be lower among older adults, particularly among individuals with later onset of the disorder, and should be increased gradually.
- Medication management of older adults should be individualized due to differences in how drugs are metabolized and to the potential of concurrent medical conditions to cause or exacerbate harmful effects and the potential of drug interactions with medications used to treat these concurrent conditions.
A review of 14 studies suggests that both typical and atypical antipsychotic drugs are effective in relieving symptoms of schizophrenia in older adults. Some studies found that atypical antipsychotic drugs were slightly more effective than typical drugs at reducing positive, negative, and affective symptoms, and that they had reduced parkinsonism, EPS, and other side. Other studies did not find differences between atypical and typical antipsychotic drugs; and Van Citters and colleagues noted methodological limitations in the studies that did find a difference between atypical and typical antipsychotic drugs (Van Citters, Pratt, Bartels, & Jeste, 2005).
Gareri and colleagues (2006) examined adverse effects of nine atypical antipsychotic medications (including a number that are not available in the U.S.) in older adults with dementia or psychotic disorders. Although they noted a reduction in EPS, compared with typical antipsychotic medications, they also noted increased plasma glucose levels in individuals with or without a history of diabetes, elevated triglycerides, and increased risk of death with some of the atypical antipsychotic drugs. Jeste and associates (2005) also reviewed the literature on use of atypical antipsychotic drugs in older adults with dementia or schizophrenia. They reported that while trials involving older adults with schizophrenia have found that atypical antipsychotics are associated with improvements in psychopathology, it is not clear whether differences in efficacy exit among the different medications (Jeste, Dolder, Nayak, & Salzman, 2005). The Agency for Healthcare Research and Quality (AHRQ) released a report looking at the comparative safety of typical and atypical antipsychotic medications based on data gathered in British Columbia (Schneeweis, Setoguchi, Brookhart, Dormuth, & Wang, 2007). Among a mixed group of older adults (including individuals with dementia, mood disorders, psychotic disorders, and comorbid medical conditions), use of atypical antipsychotic medications was not associated with a higher a mortality rate compared with use of typical or conventional antipsychotic medications.
Psychosocial Treatments
- Far fewer studies have examined the effectiveness of non-pharmacologic treatments of schizophrenia in older adults, compared to pharmacological treatments.
- Cognitive behavioral treatment (CBT), social skills training (SST), and a combined skills training and health management interventions:
- are well tolerated,
- have low dropout rates,
- are associated with positive outcomes, such as reductions in positive symptoms and depression; improved social and community functioning, cognitive insight, and independent living skills.
- Social skills training targeting instrumental skills, such as riding public transportation, improves everyday living skills among Latino older adults.
- Individual placement and support (IPS) is effective in producing paid and volunteer work among middle-aged and older adult veterans with schizophrenia.
Van Citters and colleagues (2005) reviewed five studies that investigated three manualized, psychosocial interventions developed for older adults with psychotic symptoms and disorders. These included a combined skills training and cognitive behavioral intervention (Cognitive Behavioral Social Skills Training, CBSST), a social skills training program (Functional Adaptation Skills Training, FAST), and a combined skills training and health management intervention for community-dwelling older adults with serious mental illnesses (ST+HM). These interventions were well tolerated by the participants, had low dropout rates, and were associated with positive outcomes such as reductions in positive symptoms and depression; and improvements in social and community functioning, cognitive insight (insight about delusional beliefs), and independent living skills (Van Citters et al., 2005). CBSST and FAST are listed in SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP, http://www.nrepp.samhsa.gov/).
The FAST program was used as the basis for a group intervention targeting areas, such as public transportation, that had been identified as being problematic for middle-aged and older Latinos (Programa de Entrenamiento para Desarrollo de Aptitudes para Latinos, PEDAL). Individuals treated with PEDAL performed better on measures of everyday living skills at post-treatment and at 6- and 12-month follow-up sessions, but there was no change in their psychopathology (Patterson et al., 2005).
To evaluate the success of providing work for persons with schizophrenia, Twamley and colleagues (2005) compared data from three groups of middle-aged and older veterans with schizophrenia: participants in a VA Wellness and Vocational Enrichment Clinic (WAVE), participants in Department of Rehabilitation/Education Services (DOR), and participants in Individual Placement and Support (IPS). The researchers found the following rates of paid or volunteer work among the groups: IPS, 81%; WAVE, 44%; and DOR, 29%. IPS clearly performed significantly better than WAVE and DOR, but the difference between the latter two approaches was not significant.
- A review of the behavioral and cognitive behavioral literature that includes older adults with severe mental illnesses (including but not limited to schizophrenia) suggests the following principles (Liberman, 2003):
- Biological and psychological interventions should be integrated, personally relevant goals and quality of life should be seen as more important than syndromal definitions of the disorder, and multimodal treatments should be provided to attain multidimensional improvements in the individual..
- Older adults with schizophrenia can learn to control their symptoms and manage medications, and learn and generalize social and independent living skills for community adaptation.
- Environmental supports need to be “wrapped around” to ensure that the needs of older adults with schizophrenia are being met, because it is not unreasonable to expect that these persons will need to learn or relearn the full range of skills needed to live autonomously in the community.
- Older adults with treatment refractory psychotic symptoms appear to benefit from cognitive therapy.
- Social learning and token economy procedures are effective for individuals with schizophrenia regardless of age.
- Behavior therapy appears to protect against stress-related relapse when effective in promoting coping skills and may reduce the amount of medication necessary for symptom stabilization and relapse prevention.
Notably, with the exceptions listed above, little research has been undertaken on schizophrenia in minority older adults—this includes research on either the experience or the treatment of schizophrenia.
[Final note. Although there do not appear to be any studies evaluating the effectiveness of family approaches with older adults with schizophrenia, such as those developed by Carol Anderson, Ian Faloon, or William McFarlane, social workers should consider whether these models might be appropriate for older adult clients with schizophrenia and other severe mental illnesses (SMIs) who are living with family members. These family approaches were primarily designed for parents and siblings of individuals with schizophrenia (and other SMIs). Family caretakers of older adults with an SMI include very old parents (primarily mothers), siblings, and sometimes spouses or children (Lefley, 2003).]
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Document Date: September 9, 2009
Stanley G. McCracken, PhD, University of Chicago
Zvi D. Gellis, PhD, University of Pennsylvania.
Schizophrenia in Older Adults Literature Review
This review includes a brief discussion of psychotic symptoms in older adults (psychotic symptoms in individuals with dementia are discussed in more detail in the review on dementia), a review of the literature on classification and diagnosis, course and progression of the illness, cognitive impairment and functioning, and treatment (both pharmacological and psychosocial). Since Kraepelin first described dementia praecox, hebephrenia, and paranoia (1919, cited in Harvey, 2005), there have been controversies about nearly every aspect of schizophrenia-like disorders in elderly people. There are controversies about the classification of schizophrenia and other psychotic conditions that first appear after the age of 40 or 45, about the course and progression of the illness in individuals with onset prior to 40, and about the treatment of these disorders after age 60. The confusion arises in part because study findings may differ greatly depending on the population from which the sample was selected (e.g., community-dwelling or institutionalized older adults), whether subjects with comorbid disorders (e.g., dementia and substance abuse) were included in the sample, the age range of subjects included in the study, and the age at which psychotic symptoms first appeared (e.g., before 40, 40-60, after 60, or all three groups). Additionally, diagnostic nomenclature and definitions have changed considerably over time in different diagnostic manuals. For example, in 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association [APA], 1980) prohibited a diagnosis of schizophrenia in an individual whose symptoms arose after the age of 45, and until 1992, the World Health Organization’s, International Classification of Diseases (ICD) included the diagnosis “Late Paraphrenia” that was applied to many individuals who developed schizophrenia-like symptoms late in life (World Health Organization [WHO], 1992). For purposes of the review and in accordance with recommendations of the International Late-Onset Schizophrenia Group, early onset schizophrenia (EOS) will refer to conditions that appear prior to age 40, late onset schizophrenia (LOS) to conditions that appear from 40 to 60, and very late onset schizophrenia (or schizophrenia-like psychosis) to conditions that appear after 60 (Howard, Rabins, Seeman, Jeste, & the International Late Onset Schizophrenia Group, 2000). Many of the studies looking at these three groups have used ages 45 and 65 as the dividing lines between EOS and LOS, and LOS and VLOS; these differences are noted below as needed.
Methods
An electronic search was conducted using MEDLINE, PsycINFO, Social Work Abstracts, Cochrane, DARE, PubMed, Google Scholar, and Ageline. The following search terms were grouped and used in the electronic search: (elderly, older adult, aged, geri*, gero*, senior, late onset, very late onset) AND (schizophrenia, psychosis, psychotic disorder, paraphrenia, paranoia) NOT (dement*, alzheimer, deliri*, bipolar, manic, mania, depress*, mood disorder) NOT (child*, adolesc*, youth). In addition, bibliographies of reviews and of two recent books on schizophrenia in late life (Cohen, 2003; Harvey, 2005) also were searched to identify additional relevant papers. The search focused on a variety of different studies published in the last 10 years and included systematic reviews, meta-analyses, other reviews of the literature, experimental and quasi-experimental designs. In some areas, we included descriptive studies and case reports. Initial review of papers identified in the electronic searches focused on the title of the papers and eliminated a very large number of studies of psychotic symptoms in the context of a variety of different medical conditions. The initial plan was to focus only on studies with samples of adults sixty or over. However, since most of the studies examining psychosocial interventions typically included both middle-aged and older adults, studies in this area are included if the response of older adults was reported separately or if there was no difference in response among the different age groups.
Epidemiology of Psychotic Symptoms in Older Adults
Psychotic symptoms in the elderly are more often associated with medical conditions, dementia, and other organic changes than with other psychiatric disorders. The prevalence of psychotic disorders, specifically schizophrenia and schizophreniform disorder, is low among adults over 65. Investigators in the Epidemiologic Catchment Area study (ECA), which examined rates of mental disorders in samples of community-dwelling adults 18 and over at five sites throughout the U.S., placed the prevalence for these disorders in adults 65 and over at 0.2% for 1 year and at 0.3% for lifetime (Keith, Regier, & Rae, 1991). The Surgeon General’s report on mental health placed the 1-year prevalence rate at 0.6% in this age group (U.S. Department of Health and Human Services, 1999). This is about half the rate for all adults 18 and over, and a fraction of the rate of cognitive impairment, including organic psychoses, which ranges from 16.8% to 23% (Keith et al., 1991; Myers, Weissman, & Tischler, 1984). However, when samples are taken from other sites, the rate of psychotic symptoms can rise significantly. In general, the prevalence of psychotic disorders among elderly ranges from 0.2% to 4.75% in community samples, and from 8% to 10% in geropsychiatry units and nursing homes (Zayas & Grossberg, 1998). These figures do not reflect the prevalence of psychotic symptoms in individuals with mood disorders or dementia. While the prevalence of psychotic disorders is relatively low among community-dwelling older adults, the presence of psychotic symptoms is much higher. Ostling and Skoog (2002) found that 10.1% of their sample of community-dwelling non-demented adults over 85 experienced psychotic symptoms, most of which were associated with depression, disability in daily life, and visual deficits. The rate of psychotic symptoms among individuals with dementias can be over 60% (Zayas & Grossberg, 1998). In addition to association with psychotic disorders, mood disorders and dementias, psychotic symptoms can be produced by a number of different medical conditions and their treatment, e.g., delirium; sensory impairments; drugs and medications; medical and surgical procedures; and neurological, infectious, metabolic, and endocrine disorders (Desai & Grossberg, 2003). Even in a specialty geropsychiatry clinic, the majority of older adults presenting with psychotic symptoms are diagnosed with dementia, major depression, delirium, and organic psychoses related to medical conditions and treatment (Holroyd and Laurie, 1999).
Diagnosing Schizophrenia in Older Adults
When an older adult experiences psychotic symptoms it is important to perform a differential diagnosis to identify the reason for these symptoms, and in particular, to rule out/identify medical and pharmacological precipitants of these symptoms. Desai and Grossberg (2003) presented a decision tree for diagnosing psychotic symptoms in older adults. A number of the steps in their decision tree involve medical determinations, which of course means that a physician must be involved in determining the etiology of the psychotic symptoms. However, this is not markedly different from making decisions about psychotic symptoms in a younger person, in that medical and drug-related causes always must be ruled out before one makes a diagnosis of a psychiatric disorder. The difference is that with older adults, there is a higher likelihood that the symptoms are caused by delirium, dementia, and the presence or treatment of other medical conditions. Much of the information needed to make a determination about the etiology of psychotic symptoms can be gathered by a social worker and shared with the physician, such as information about the presence and change in functioning, losses, and other stressors, quality of life, living situation, symptoms, personal and family history, the use of drugs and medications, and even some information about the individual’s medical history. The first step in the decision tree is to take a thorough history to determine whether the individual has experienced psychotic or other psychiatric symptoms, has had a current or prior psychiatric diagnosis or treatment, or has a family history of psychiatric problems (e.g., psychotic or mood disorders, suicide, dementia). This history should be taken from both the individual and one other person who is quite familiar with him or her. The initial purpose of this assessment is to determine the nature of the symptoms, when they started, and their relationship with any stressors, along with the degree of impairment and distress that the symptoms are causing. Cognitive impairment is associated with schizophrenia; however, the progression of cognitive decline in an aging individual with schizophrenia parallels the decline seen in normal aging (an issue that will be addressed in more detail later). Significant cognitive decline should raise the index of suspicion about the presence of dementia, which may be comorbid with another psychiatric disorder. Similarly, recent changes in orientation, awareness of the environment, or ability to attend should alert one to the possibility of delirium. Finally, the social worker should gather information on the use of prescribed medications; alcohol and other non-medical drugs, over-the-counter drugs, and herbal preparations. This information is provided to the physician who will review the client’s medical condition, including considering the possibility of structural brain lesion or stroke (Desai & Grossberg, 2003). After secondary causes have been ruled out or identified, psychotic symptoms related to a previous psychiatric diagnosis should be considered. In cases where there is no prior history of psychiatric disorders, the individual may be experiencing a late-life psychotic disorder or late-life mood disorder with psychotic features.
Older Adults with Early Onset Schizophrenia
There are two conflicting views of EOS. The first is that schizophrenia has a course that is chronic and, if not deteriorating, is stable and usually nonremitting (Kraepelin, 1919, cited in Harvey, 2005). The second is the idea that positive symptoms (such as hallucinations and delusions) “burn out” over time and are replaced by increasing negative symptoms (such as reduced affective experience and expression and reduced verbal output), (Harvey, 2005). This section reviews both the issue of recovery from schizophrenia across time and changes in the pattern of symptoms and functional impairment over time. Changes across time have been studied in both long- and short-term longitudinal studies and in cross-sectional studies comparing older with younger clients with schizophrenia and comparing older adults with schizophrenia with older adults with no mental illness or with other mental illness, including dementia. These studies have sampled individuals living in the community and individuals living in institutions, such as long-term care facilities and hospitals. Taken together, the research findings indicate a wide variety of outcomes among individuals with EOS, including a substantial proportion of individuals who recover over time, and a wide variety of symptom patterns among individuals with EOS, much of which depends on whether the participants were from community or institutional settings.
Long-term Recovery
Harding (2003) reviewed 10 long-term (>20 years) longitudinal studies looking at recovery from schizophrenia over time. The studies conducted in Europe and Japan consisted primarily of individuals living in urban areas, whereas the U.S. studies sampled individuals living in rural areas. A number of these studies included individuals who were older adults at the time of follow-up investigations, and most studies examined both clinical improvement and social or functional improvement. Finally, the subjects in most of the studies had the onset of symptoms during the 1930s, 40s, and 50s—prior to the development of antipsychotic medications. Thus it is likely that few of the subjects would have received medication treatment for the initial episode of their illness, and none would have received treatment with atypical antipsychotic medications. The criteria and methods used to identify individuals with schizophrenia varied widely among the studies, with some studies using broader and others narrower definitions of schizophrenia. From the methods reported, the majority of the subjects in the studies would likely meet DSM-IV criteria for schizophrenia. Global ratings of recovery were made for participants in the studies. “Recovered = having no further symptoms, no use of psychotropic drugs, living independently in the community, working, and relating well to others, with no behaviors that are considered to be odd or unusual; significantly improved = all of the above but one domain of functioning,” (Harding, 2003, p. 22). The rate of recovery or significant improvement ranged from 46% to 84% for clinical recovery and from 21% to 77% for social recovery; thus, there is considerable variability in the rate of recovery, particularly for social/functional recovery. Findings from these 10 longitudinal studies challenge the notion that schizophrenia has a chronic, deteriorating course with little hope of recovery. Clearly, these findings contradict the Kraepelinian notion of a chronic, unremitting course—some people do recover over time. However, data from cross-sectional and more recent short-term follow-up studies indicate that a number of older adults with schizophrenia do have substantial levels of impairment.
Symptoms in Late Life
In contrast to the global assessment of the presence and severity of various symptoms characteristic of the long-term longitudinal studies reviewed by Harding, more recent cross-sectional and short-term follow-up studies have conducted formal assessments of symptom severity and functioning using standardized instruments. The classical view of schizophrenia is that the severity of psychotic symptoms in later life is much reduced (referred to as symptom burn-out) and that these symptoms are replaced by greater negative symptoms. Several factors should be considered when examining the literature in this area. First, does the sample include only older adults or both middle-aged and older adults? Second, was the sample drawn from institutionalized individuals, community-dwelling individuals, or both? Third, does the sample include individuals with co-morbid conditions, such as substance abuse problems, medical conditions, or dementia? Finally, is the study biased by attrition due to the high mortality rate, including from suicide, of individuals with schizophrenia. That is, are people with certain symptom patterns more likely to die early than those with other kinds of symptoms.
Several cross-sectional studies have examined positive symptoms (e.g., delusions, hallucinations, paranoia) and negative symptoms (e.g., anhedonia, blunted affect, and avolition) in older adults. Davidson and colleagues (1995) examined the severity of positive and negative symptoms in adults ranging in age from 25 to 95, all of whom were chronically hospitalized at the time of the study. Subjects were divided into 10-year age groups (e.g., 25-34, 35-44,…85 and over). Although they found a linear decrease in severity of positive symptoms from ages 25 to 95, individuals over 65 continued to experience significant psychotic symptoms. The researchers also found an age-related increase in severity of negative symptoms and cognitive impairment, and a positive correlation between negative symptoms and cognitive impairment (Davidson et al., 1995). Harvey and associates (1998) investigated older adults (>65) with schizophrenia who either were chronically hospitalized, were living in nursing homes, or were acutely admitted to a gero-psychiatry unit of the hospital. Individuals who were acutely admitted had been living in the community, either with relatives or in community residences (both with and without professional staff onsite). They found that each group could be differentiated from the other two. Nursing home residents were older, had the least severe positive symptoms, and had the most severe adaptive deficits. Chronically hospitalized and acutely admitted individuals were similar in severity of positive symptoms. Compared to chronically hospitalized and nursing home residents, individuals acutely admitted from the community had better cognitive functioning, better adaptive functioning, and less severe negative symptoms. Cognitive impairment was a stronger predictor of adaptive functioning than either positive or negative symptoms, and this was true across all sites and all levels of severity of illness (Harvey et al., 1998). Both the Davidson and Harvey results demonstrate that the positive symptoms of schizophrenia continue throughout life, at least among individuals with chronic symptoms or who require hospitalization due to exacerbation of symptoms.
Although the above cross-sectional studies provide important data, many individuals with schizophrenia do not have numerous hospitalizations in later life (Harvey, 2005). Jeste and colleagues (2003) have conducted a number of studies of community-dwelling adults (40-85 y.o.) with schizophrenia, including a study comparing these individuals with healthy individuals of the same age (Jeste et al., 2003). Adults with schizophrenia were more impaired than the healthy controls on a number of measures, such as life skills, quality of well-being, and cognitive functioning. Adults with schizophrenia experienced an age-related decrease in severity of psychotic symptoms but no age-related decline on quality of well-being or everyday functioning (Jeste et al., 2003). The same researchers compared two community-dwelling groups with schizophrenia: middle-aged and older adults (Eyler-Zorrilla et al., 1995). They found that older adults experienced less severe symptoms overall and were on lower doses of antipsychotic medications than were middle-aged individuals. Depending on which measure was used, the older group experienced less prominent (or equivalent) positive symptoms and more prominent (or equivalent) negative symptoms, and they were more cognitively impaired. This increased global cognitive impairment, however, reflected a normal degree of decline since the degree of change was equivalent to that of a healthy comparison group. Short-term longitudinal data of individuals from their 40s to their 90s, living in a variety of settings (community, nursing home, and hospital), indicate no evidence of improvement in symptoms over periods of 1 to 6 years (e.g., Harvey et al., 2003; Heaton al., 2001). Taken together these data suggest that some older adults with schizophrenia have significant levels of positive symptoms that are stable over time (Harvey, 2005).
In contrast to the number of studies that have examined positive symptoms among older adults, few have examined thought disorder in detail. Bowie and colleagues (2005) divided thought disorder into two components: positive thought disorder (sometimes called disconnection or disorganization syndrome), which involves abnormalities in the production of language such as derailment and tangentiality, and negative thought disorder, which denotes a reduction in the amount of overall amount or information in speech including poverty of speech and poverty of content of speech. They observed 220 middle-aged and older adults (age range 49-97, mean 74.9) with schizophrenia an average of 2.3 years (range 1-6 years). They evaluated cognitive impairment (Mini-Mental State Examination, MMSE, Folstein, Folstein, & McHugh, 1975), disconnection, and verbal productivity (negative thought disorder). Among the study participants, verbal underproductivity worsened over time, particularly among adults 75 and older, but disconnection remained stable. Further, worsening verbal underproductivity was associated with worsening of cognitive impairment as measured by the MMSE (Bowie et al., 2005). One of the implications of the study findings was that some of the observed age-related decrease in positive symptoms may have occurred because some individuals were not reporting these symptoms because they just were not talking very much, about symptoms or anything else.
Cognitive Impairment
From the time of Kraepelin’s work, impaired cognitive functioning has been seen as a hallmark of schizophrenia, and numerous researchers have investigated longitudinal changes in cognitive functioning and its association with other symptoms. One of the key questions is whether the rate of cognitive impairment accelerates, reverses, or stays the same over time. The research findings in this area are controversial. Studies showing cognitive decline have mostly been conducted in individuals over 65 with a chronic course of institutionalization and currently living in hospitals or nursing homes. Studies showing less evidence of cognitive decline (i.e., no more than would be associated with benign aging) have typically included younger, community-dwelling individuals with no evidence of chronic institutional stays and a better lifetime course of the illness (Harvey, 2005; Kurtz, 2005). Deficits in social and adaptive functioning are most strongly associated with cognitive deficits, only weakly associated with negative symptoms, and not associated with positive symptoms; furthermore, functional deficits tend to be preceded by deficits in cognition (Friedman, Harvey, McGurk, White, & Parrella, 2002; Harvey, 2005). There are a number of limitations to this research. One of the most significant limitations is the dearth of longitudinal studies with specific measures of cognitive functioning or performance measures of adaptive functioning—particularly among community-dwelling older adults. Studies with measures testing specific areas of cognitive functioning are needed to identify the specific pattern of cognitive impairments seen among older adults, since the specific pattern of changes has implications for caregiving and even residential status (e.g., nursing home versus community). Performance measures of functioning are important because the validity of caregiver reports differs greatly between, for example, family caregivers and nursing home staff. Poor insight may reduce the validity of self-report of functioning. Furthermore, the likelihood of deterioration of functioning in a specific area is influenced by whether the individual has the opportunity to perform the activity. For example, individuals living in institutional settings are not allowed to cook their own meals, drive, or in many cases, manage their own funds.
One final note should be made about late-life changes in EOS. One should expect large cohort effects among this population. For example, each subsequent 10-year age cohort is more likely to have received antipsychotic medications early in the course of the illness (perhaps during the first episode), more likely to have been treated with atypical antipsychotic medications, less likely to have spent large portions of their lives in institutions, more likely to have received well-designed psychiatric rehabilitation services, and more likely to have used street drugs like marijuana, cocaine, and other illicit drugs. It is unclear what the effect of all this will be on symptoms, cognition, or functioning.
Late Onset Schizophrenia (LOS) and Very Late Onset Schizophrenia(-like Psychosis) (VLOS)
One of the most controversial issues in late-life schizophrenia is the existence of late onset schizophrenia (LOS). As noted earlier, one of the problems is that psychotic symptoms emerge in a variety of contexts in later life—they may be associated with mood disorders, dementia, medical disorders, or drug-related conditions, as well as schizophrenia. Research in this area is limited by the fact that, in the absence of treatment records, it is difficult to reliably determine the age of onset of symptoms of schizophrenia. Common unawareness of the illness as well as memory impairments make retrospective judgments about the timing of symptom onset suspect. This literature also is plagued by classification and terminology issues. The DSM-III prohibited a diagnosis of schizophrenia if the onset of symptoms was after age 45 and DSM-III-R provided a specifier to be used for onset after 44 (APA, 1980, 1987). The term paraphrenia was introduced by Kraepelin (1894, cited in Howard, 2001) and was re-introduced as late paraphrenia by Roth and Morrisey to describe individuals with an onset of schizophrenia after 55 or 60 (1952; Roth & Kay, 1998). The apparent syndromic coherence of paraphrenia (experiencing hallucinations and delusions in the absence of functional deterioration or disturbance of affective response), including predominance among women, and abnormal pre-morbid personality and social functioning led it to be included in the ninth edition of the International Classification of Diseases (ICD-9, WHO 1980) (Howard et al., 2000). However, neither ICD-10 nor DSM-IV or DSM-IV-TR provides a separate code for late onset schizophrenia (WHO, 1992; APA, 1994, 2000). Although neither ICD nor DSM distinguishes between EOS and LOS or VLOS, the debate about whether these are the same or different conditions is by no means settled (Almeida, Howard, Levy, & Anthony, 1995; Jeste, Blazer, & First, 2005; Mazeh, Zemisblani, Aizenber, & Borak, 2005).
There are several ways in which EOS differs from onset in later life. Later onset is characterized by greater prevalence of visual, tactile, and olfactory hallucinations; persecutory, partition (belief that people, animals, materials or radiation can pass through a structure that would normally constitute a barrier), reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations. Later onset also is associated with a lower prevalence of formal thought disorder and affective flattening or blunting. Both formal thought disorder and negative symptoms are very rare in onset after 60 (Almeida et al. 1995; Howard, 2001; Howard et al., 2000; Palmer, McClure, & Jeste, 2001). Individuals with LOS and particularly VLOS appear to have a reduced prevalence of schizophrenia among family members, compared with individuals with EOS (Howard, 2001). Other risk factors for later onset schizophrenia include female gender, cognitive impairment, and possibly sensory impairment (Wynn, Owen, & Castle, 1999). While the lifetime incidence of schizophrenia is the same for men and women, onset during their 20s to mid-30s is predominant among men, whereas women have a second onset peak in their late 40s to mid-50s. The correspondence of this second peak with onset of menopause has led a number of authors to speculate about a potential role of estrogen as a protective factor against development of schizophrenia (Palmer et al., 2001). Although cognitive impairment is a risk factor for development of schizophrenia in late life, schizophrenia should not be viewed as a variant of dementia. Palmer and colleagues (2003) compared 1- and 2-year changes in cognitive functioning among adults with LOS (>45), EOS, Alzheimer’s disease with psychotic symptoms (AD), and normal subjects. They found that EOS, LOS, and normal subjects were comparable and had relatively stable cognitive functioning but that AD subjects had greater declines than either of the other groups, suggesting that there was no evidence of progressive deterioration among community-dwelling individuals with LOS (Palmer et al., 2003). One final comment on LOS and VLOS is the observation that people with onset later in life may respond to lower doses of antipsychotic medication than individuals with onset earlier in life (Wynn et al., 1999).
Treatment
Pharmacologic Treatment
Five reviews of antipsychotic medication treatment of schizophrenia in older adults have been published in the last 5 years. Neither of the two Cochrane reviews found sufficient evidence upon which to base treatment recommendations (Arunpongpaisal, Ahmed, Aqeel, & Paholpak, 2003; Marriott, Neil, & Waddington, 2006) (Level B). Van Citters and colleagues (Van Citters, Pratt, Bartels, & Jeste, 2005) examined both pharmacologic and nonpharmacologic (discussed later) treatments for older adults with schizophrenia. They reviewed five double-blind, randomized controlled trials (RCTs) plus a number of open-label RCTs, quasi-experimental studies, and large prospective single-agent trials. Taken together, these studies show that both typical and atypical antipsychotic drugs are effective in relieving symptoms of schizophrenia in older adults (Level B). Some studies found that atypical antipsychotic drugs were slightly more effective typical drugs at reducing positive, negative, and affective symptoms, and that they had reduced parkinsonism, extrapyramidal symptoms (EPS), and other side effects. Other studies did not find differences between atypical and typical antipsychotic drugs; and the reviewers noted methodological limitations in the studies that did find a difference between atypical and typical antipsychotic drugs. They also noted that all but 3 of the 14 studies they reviewed were funded by pharmaceutical companies and recommended that this support should be considered in evaluating the studies because of the potential for conflicts of interest (Van Citters et al., 2005).
There have been two reviews of atypical antipsychotic drugs in the elderly, including studies of individuals with dementia, as well as those with schizophrenia. Gareri and colleagues (2006) examined adverse effects of nine atypical antipsychotic medications, including a number that are not available in the U.S. They used the WHO definition of an adverse drug reaction as, “a harmful, non-intentional reaction caused by a drug at the commonly used doses for prophylaxis, diagnosis, and therapy” (p. 938). While they noted a reduction in EPS, compared with typical antipsychotic medications, they also noted increased plasma glucose levels in individuals with or without a history of diabetes, elevated triglycerides, and increased risk of death with some of the atypical antipsychotic drugs. The authors reported that antipsychotic drugs have value in treatment of psychotic symptoms in older adults, that doses needed to be individualized and slowly increased, that individual pharmacological characteristics need to be considered to avoid dangerous accumulation of medications and potentially harmful adverse affects, and that drug interactions must always be considered, particularly in individuals with co-morbid conditions (Gareri et al., 2006) (Level E). Jeste and associates (2005) also reviewed the literature on use of atypical antipsychotic drugs in older adults with dementia or schizophrenia. They reported that while trials involving older adults with schizophrenia have found that atypical antipsychotics are associated with improvements in psychopathology, it is not clear that there are differences in efficacy among the different medications (Jeste, Dolder, Nayak, & Salzman, 2005) (Level E). White and colleagues (2006) (Level C) did a naturalistic, retrospective comparison of typical and atypical antipsychotic drugs on chronically hospitalized older adults with schizophrenia. They found that both cognitive functioning and self-care skills declined over time and that there was no difference between the two categories of drugs in their ability to reverse this decline. Furthermore, atypical antipsychotic drugs produced no effect on the progressive worsening of negative symptoms among this group of hospitalized individuals (White et al., 2006). The Agency for Healthcare Research and Quality (AHRQ) released a report looking at the comparative safety of typical and atypical antipsychotic medications based on data gathered in British Columbia (Schneeweiss, Setoguchi, Brookhart, Dormuth, & Wang, 2007). Specifically the researchers compared the risk of death among older adults who filled prescriptions for these two classes of drugs. Since the study was based on prescriptions filled rather than diagnosis, individuals in the study had a range of disorders including dementia, delirium, mood disorders, psychotic disorders, and other psychiatric disorders. Additionally, medical co-morbidity was widespread. The authors found that 14.1% of older adults who took typical antipsychotic medications died, compared with 9.6% of those who took atypical antipsychotic medications (unadjusted mortality ratio: 1.47). The greatest mortality increase was associated with use of higher (>median) dosages and was during the first 40 days after beginning use. This suggests that among this mixed group of older adults, use of atypical antipsychotic medication was not associated with a higher mortality rate, compared with use of typical or conventional antipsychotic medication (Schneeweis et al., 2007).
Overall, this literature suggests the following.
- Antipsychotic medication is effective in reducing psychotic symptoms in older adults with schizophrenia (Level A).
- It is not clear whether any drug or category of drugs is any more effective than any other.
- Adverse effects differ between the typical and atypical medications with typical medication having increased EPS (particularly tardive dyskinesia in older adults) and atypical medication having increased risk of elevated glucose and tri-glycerides; however, risk of death is not higher among users of atypical compared to typical antipsychotic medications.
- Doses may need to be lower among older adults, particularly among individuals with later onset of the disorder, and should be increased gradually.
- There is a need to individualize medication management of older adults due to differences in how drugs are metabolized and to the potential of concurrent medical conditions to cause or exacerbate harmful effects and the potential of drug interactions with medications used to treat these concurrent conditions.
Psychosocial Treatments
There are far fewer studies examining the effectiveness of non-pharmacologic treatments of schizophrenia in older adults compared to pharmacological treatments. Van Citters and colleagues (2005) found five studies: two RCTs (Level A), two quasi-experimental studies (Level B), and one noncontrolled prospective cohort study (Level C). These studies investigated three different manualized, psychosocial interventions developed for older adults with psychotic symptoms and disorders: a combined skills training and cognitive behavioral intervention (Cognitive Behavioral Social Skills Training, CBSST), a social skills training program (Functional Adaptation Skills Training, FAST), and a combined skills training and health management intervention for community-dwelling older adults with serious mental illnesses (ST+HM). These interventions were well tolerated by the participants; had low dropout rates; and were associated with positive outcomes, such as reductions in positive symptoms and depression, and improved social and community functioning, cognitive insight (insight about delusional beliefs), and independent living skills (Van Citters et al., 2005). In addition to those reported in the preceding review, three additional studies were located, including a follow-up of the CBSST studies; an intervention, based on FAST, developed for older Latinos with chronic psychosis; and a comparison of three approaches to work rehabilitation for middle-aged and older people with schizophrenia. Granholm and colleagues (2007) reported that the greater skill acquisition, self-reported performance of living skills in the community, but not the greater cognitive insight were maintained at a 12-month follow-up session of CBSST (Granholm et al., 2007). The FAST program was used as the basis for a group intervention targeting areas, such as public transportation, that had been identified as being problematic for middle-aged and older Latinos (Programa de Entrenamiento para Desarrollo de Aptitudes para Latinos, PEDAL). PEDAL was compared to a time-equivalent support group (SG) protocol in an RCT conducted at three psychiatric clinics specializing in care of Latinos. Individuals treated with PEDAL performed better at post-treatment and at 6- and 12-month follow-up examinations on measures of everyday living skills, but there was no change in psychopathology (Patterson et al., 2005). Twamley and colleagues (2005) compared data from three groups of middle-aged and older veterans with schizophrenia: participants in a VA Wellness and Vocational Enrichment Clinic (WAVE), participants in Department of Rehabilitation/Education Services (DOR), and participants in Individual Placement and Support (IPS). WAVE integrated vocational and psychiatric services and offered a variety of wellness programs in addition to psychiatric and vocational services. DOR was run on a traditional vocational rehabilitation model with determination of eligibility (which could take up to 60 days), followed by 3-5 weeks of employment preparation preceding job development. IPS was a train-place model that does not include prevocational classes prior to the job search but does provide time-unlimited follow-along support onsite. The authors found the following rates of paid or volunteer work among the groups: IPS, 81%; WAVE, 44%; and DOR, 29%. IPS performed significantly better than WAVE and DOR, but no difference was found between the latter two approaches (Twamley et al., 2005). Finally, Liberman (2003) reviewed a number of behavioral and cognitive behavioral interventions that had included elderly individuals with severe mental illnesses, including, though not always limited to, schizophrenia. He identified the following principles:
- Biological and psychological interventions should be integrated, personally relevant goals and quality of life should be seen as more important than syndromal definitions of the disorder, and multimodal treatments should be provided to attain multidimensional improvements in the individual.
- Older adults with schizophrenia can learn to control their symptoms and manage medications and learn and generalize social and independent living skills for community adaptation.
- Environmental supports need to be “wrapped around” to ensure that the needs of older adults with schizophrenia are being met, because it is not unreasonable to expect that these persons will need to learn or relearn the full range of skills required to live autonomously in the community.
- Older adults with treatment refractory psychotic symptoms appear to benefit from cognitive therapy.
- Social learning and token economy procedures are effective for individuals with schizophrenia of all age groups.
- Behavior therapy appears to protect against stress-related relapse when effective in promoting coping skills and may reduce the amount of medication necessary for symptom stabilization and relapse prevention (Liberman, 2003).
Summary: Take Home Points for Teaching
- Prevalence. The prevalence of schizophrenia among individuals over age 65 is lower than the prevalence among younger individuals. The prevalence of psychotic symptoms is much higher among older adults. However, psychotic symptoms are more often associated with medical conditions and treatment, delirium, dementia, and depression, than with psychotic disorders.
- Diagnosis. Diagnosing psychotic disorders in older adults requires a careful differential diagnosis in collaboration with a physician due to the need to rule out psychotic symptoms secondary to general medical conditions, medication and other drug use, delirium, and dementia.
- Early Onset Schizophrenia (EOS). There is considerable variability in the literature regarding the long-term outcome of early onset (<40) schizophrenia, much of this variability depends on the methodology (long-term vs. short-term follow-up, longitudinal vs. cross-sectional, global ratings of improvement or functioning vs. ratings of specific symptoms or patterns of functioning) and the population that is sampled (community-dwelling vs. institutionalized).
- Recovery. There is evidence that a substantial proportion of individuals with EOS recover or are significantly improved over time. This is true both for clinical and social recovery.
- Symptoms.
- There is evidence that a number of individuals with schizophrenia continue to experience significant positive symptoms in later life and that severity of these symptoms either decreases or stays the same.
- There is evidence that negative symptoms may increase in severity particularly among individuals living in hospitals or nursing homes; it is not clear that this is true of individuals living in the community.
- Individuals with schizophrenia experience more cognitive impairment than individuals without schizophrenia but less than individuals with dementia. The rate of decline in cognitive functioning among individuals living in the community is similar to that found among individuals without schizophrenia, but the rate of cognitive decline among individuals living in institutions is more rapid. Cognitive impairment is a stronger predictor of adaptive functioning than either positive or negative symptoms.
- Late Onset Schizophrenia (LOS) and Very Late Onset Schizophrenia (or Schizophrenia-like Psychosis, VLOS). It is important to remember that, in the absence of accurate treatment records, it is difficult determining the exact age of onset of symptoms of schizophrenia. There has been considerable variability over the past several decades in the nomenclature and definitions used to describe the condition experienced by individuals who have an onset of schizophrenia symptoms after age 40 (LOS) or 60 (VLOS).
- Symptoms. Individuals with onset in later life experience more visual, tactile, and olfactory hallucinations; persecutory, partition, reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations than do those with EOS. They also experience a lower level of formal thought disorder and affective flattening or blunting. Formal thought disorder and negative symptoms are rare in VLOS.
- Familial and Risk Factors. Individuals with LOS and VLOS appear to have a reduced prevalence of schizophrenia among family members, compared with individuals with EOS. Risk factors for later onset include female gender, cognitive impairment, and possibly sensory impairment.
- Treatment. It has been reported that people with onset in later life may respond to lower doses of antipsychotic medication than individuals with earlier onset.
- Overview of Treatment Research.
- Pharmacological Treatments.
- Antipsychotic medication is effective in reducing psychotic symptoms in older adults with schizophrenia.
- No any one drug or category of drugs (atypical or typical/conventional) appears to be any more effective than another.
- Adverse effects differ between atypical and typical medications. Atypical medications have increased risk of elevated glucose and triglycerides; typical medications have increased risk of EPS (particularly tardive dyskinesia). Though a number of reports have noted elevated risk of death in individuals taking some atypical antipsychotic medications, there is evidence that the death rate is higher among individuals taking typical antipsychotic medications, particularly among those taking higher doses and in the first 40 days of treatment.
- Doses may need to be lower, particularly among individuals with later onset of symptoms, and should be raised slowly. As in other psychotropic medications, the rule appears to be “start low and go slow.”
- Medication management should be individualized with awareness of differences in metabolism, concurrent medical conditions, and the potential for drug interactions with other medications and with non-medical drug use, particularly alcohol.
- Psychosocial Treatments.
- There are relatively few RCTs of interventions addressing schizophrenia in older adults. Existing studies typically include both middle-aged and older adults.
- Many of the recommendations about psychosocial treatments for older adults with schizophrenia are extrapolations from interventions designed for and evaluated in younger individuals. Most of the interventions studied in older adults are adapted from interventions initially developed for younger adults.
- The available limited evidence supports the use of interventions based on cognitive behavioral therapy, social skills training, health management, behavior therapy, and individual placement and support approaches.
- Finally, the high probability of a pronounced cohort effect needs to be considered when describing, understanding, and providing services to older adults with psychotic disorders. Each successive cohort of older adults 1) will be more likely to have been treated with antipsychotic medication early in the course of their illness, regardless of date of onset; 2) will have spent relatively more time in the community and less time in institutions; 3) will be more likely to have been exposed to effective evidence-based psychosocial and psychiatric rehabilitation interventions, including community-based interventions of various kinds; and 4) will be more likely to have been exposed to (or still be using) a wide variety of non-medical drugs in addition to alcohol.
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Palmer, B. W., Bondi, M. W., Twamley, E. W., Thal, L., Golshan, S., & Jeste, D. V. (2003). Are late-onset schizophrenia spectrum disorders neurodegenerative conditions? Annual rates of change on two dementia measures. The Journal of Neuropsychiatry and Clinical Neurosciences, 15, 45-52.
Palmer, B. W., McClure, F. S., & Jeste, D. V. (2001). Schizophrenia in late life: Findings challenge traditional concepts. Harvard Review of Psychiatry, 9, 51-58.
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Schneeweiss, S. Setoguchi, S., Brookhart, A. Dormuth, C., & Wang, P. S. (2007). Comparative safety of conventional and atypical antipsychotic medications: Risk of death in British Columbia seniors. Effective Health Care Research Report No. 2. (Prepared by Brigham and Women’s Hospital DEcIDE Center Under Contract No. HSA29020050016I.) Rockville, MD: Agency for Healthcare Research and Quality. August 2007. Retrieved from www.effectivehealthcare.ahrq.gov/reports/final.cfm.
Twamley, E., Padin, D. S., Bayne, K. S., Narvaez, J. M., Williams, R. E., & Jeste, D. V. (2005). Work Rehabilitation for middle-aged and older people with schizophrenia: A comparison of three approaches. Journal of Nervous and Mental Disease, 193(9), 596-601.
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Van Citters, A. D., Pratt, S. I., Bartels, S. J., & Jeste, D. V. (2005). Evidence-based review of pharmacologic and nonpharmacologic treatments for older adults with schizophrenia. Psychiatric Clinics of North America, 28(4), 913-939.
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Wynn Owen, P. A., & Castle, D. J. (1999). Late-onset schizophrenia: Epidemiology, diagnosis, management and outcomes. Drugs & Aging, 15, 81-89.
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Document Date: September 9, 2009
- Folsom, D. P., Lebowitz, B. D., Lindamer, L. A., Palmer, B. W., Patterson, T. L., & Jeste, D. V. (2006). Schizophrenia in late life: Emerging issues. Dialogues in Clinical Neuroscience, 8, 45-52.
Provides a good, brief, overview of several major areas of research and clinical care that are particularly relevant to older adults with schizophrenia. Includes a discussion of the public health challenges and cost of care, course of the illness, cognition, medical care and comorbidity, and treatment concerns related to use of atypical antipsychotic drugs.
- Palmer, B. W., McClure, F. S., & Jeste, D. V. (2001). Schizophrenia in late life: Findings challenge traditional concepts. Harvard Review of Psychiatry, 9, 51-58.
Excellent overview and discussion of research on both EOS and LOS. More detailed discussion of research than that in Folsom et al., particularly research on cognitive functioning and neuropsychology, family history, and clinical characteristics.
- Van Citters, A. D., Pratt, S. I., Bartels, S. J., & Jeste, D. V. (2005). Evidence-based review of pharmacologic and nonpharmacologic treatments for older adults with schizophrenia. Psychiatric Clinics of North America, 28, 913-939.
Excellent systematic review of the treatment of schizophrenia in older adults. Even though this review was published in 2005, little has been published since that would change the findings. The research is limited for both pharmacologic and nonpharmacologic interventions—particularly the latter.
Additional readings for students who would like to explore this issue in more detail.
- Cohen, C. I. (Ed.). (2003). Schizophrenia into later life: Treatment, research, and policy. Washington, DC: American Psychiatric Publishing.
- Harvey, P. D. (2005). Schizophrenia in late life: Aging effects on symptoms and course of illness. Washington, DC: American Psychological Association.
Both of these books are thoughtful, well-written, and provide a comprehensive discussion of EOS, LOS, and VLOS. Both discuss clinical characteristics, comorbidity, psychosocial issues, medication treatment, and psychosocial treatment. Both are well referenced. The Cohen book, though older, has chapters written by many of the major scholars in the field.
Document Date: September 9, 2009
Rose W. is a 69-year-old retired, African American woman who lives independently in her own apartment. Her 48-year-old son lives in the same apartment building as she does, but on a different floor; he sees her several times a week. Mrs. (not Ms.) W. married her son’s father when she was 19 and divorced him 5 years later. She has not been married or had a significant romantic relationship since then. She retired from work cleaning houses and cooking about 5 years ago, and she receives Social Security and Medicare. Mrs. W. has hypertension, arthritis, and Type II diabetes, all of which are being controlled by medications. She had been receiving care in a neighborhood clinic for a number of years, until the clinic closed. She came to the attention of the social worker when she was seen for an initial appointment by a primary care resident (PCR) in the ambulatory care clinic of a large metropolitan teaching hospital. Her PCR referred her because he was concerned about what he thought were psychotic symptoms. Interviews with Mrs. W. and her son revealed the following information:
- Mrs. W. hears people whispering or, rarely, talking, particularly if she is not busy or is not listening to the radio or TV. As near as we can ascertain, she has had these experiences since she was a young woman. When asked about the possibility that these experiences might be a misinterpretation of sounds coming from her radiator, the radio or another appliance, or from other apartments, her son said that he had been with her sometimes when this occurred and that there seemed to be no external trigger, and that as far as he knew she had always been like that.
- Ms. W. also said that she felt that “the two homosexuals next door” were watching her, and she stated at one point in the interview that she thought that perhaps the PCR and social worker “might be together.” When asked about this, she didn’t want to say more but seemed suspicious when we were both in the room with her at the same time. Her son also said that she had had these kinds of ideas for as long as he knew and that her family had always thought that she was odd that way. That is, she would, for no apparent reason, become suspicious of other people around her. He said that he and the family members used to try to “talk some sense into her,” but no one had ever had any luck with this approach. He said that people had learned that the best thing to do was to just ignore these kinds of things, and these ideas would usually go away, except for her ideas about her neighbors who were always very kind to her. He said that she often was suspicious of people that she had just met and believed either that they were lovers or that they were watching her. “Normally, once she gets used to you, she’s fine, but not at first.”
- Her son said that neither the auditory hallucinations nor the delusions/over-valued ideas had ever interfered with her ability to work, go to church, or function in other ways. He said that, as far as he knew, she had never been referred to a mental health professional nor received treatment for these problems. He also said that there had been no changes in either of these conditions in the past months.
- Mrs. W. says that she spends most of her days watching TV, listening to the radio, reading the Bible, or doing errands. She goes to church every Sunday and to prayer meeting Wednesday nights. She participates in church social activities a couple times a month, has a couple friends that she sees about once every week or two, and has extended family that she sees at about the same frequency, though she sees her son at least once a week.
- Mrs. W. did not want to discuss her family history, but her son said that he thought that an uncle (Mrs. W’s brother) had been in a local psychiatric hospital for drug abuse and “nerves.” It sounded like he may have had PTSD subsequent to service in the Korean conflict. Another family member had a nervous breakdown, but no one ever talked about the details.
Activity #1. Class Discussion
Ask your students to discuss this case.
- Do the students believe that these are psychotic symptoms, normal and expected occurrences in someone living alone, or is she just odd? What additional information would they want to gather, if any, to decide what sort of experiences she is having?
- Given the above information what might they recommend to the PCR? Why? What additional information, if any would they want to gather before making a recommendation to the PCR?
- In the unlikely event that the class has difficulty with coming up with possibilities, some of the options might include:
- Suggest that the PCR refer Mrs. W. to a psychiatrist for evaluation and possible treatment of the psychosis. Continue to follow and treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Referral option)
- Suggest that the PCR prescribe an appropriate antipsychotic (or other) medication to Mrs. W. Medication monitoring as appropriate with frequent follow-up visits while she is being stabilized on the medication, then tapering the visits to a less frequent schedule. Continue to observe and treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Medication option)
- Suggest that the PCR not take any action on the psychotic symptoms at the present time. Instead continue to observe and treat her medical condition as appropriate, but with more frequent (monthly) visits to the primary care clinic in order to build a relationship with her and to monitor her psychotic symptoms and functioning. (Watchful monitoring option)
- Suggest that the PCR pay no attention to the psychotic symptoms unless they become severe or she needs hospitalization. Continue to follow and treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Do nothing now option)
- Suggest that the PCR ask her son to keep close tabs on his mother, systematically monitoring her symptoms on a frequent (every day or two) basis. Continue to observe her and to treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Family observation option.)
Activity #2. Role play
Ask the students to divide into groups consisting of the following: Mrs. W., her son, the PCR, and the social worker. Ask each group to pick an option from above and role play the social worker conversations with the PCR, Mrs. W., and her son. If they ask whether the conversations should be conducted with each individually or with groups (e.g., Mrs. W. and her son together), suggest that is up to the group, but they should be able to explain the rationale behind their decision.
Activity #3. Class Discussion
Have the class read and discuss the social worker’s reasoning for the action that he took in this case (see below). List the advantages and risks of this approach. Are there other options that would be better?
The social worker in this case chose Option #3-Watchful monitoring. His reasoning was that it is very likely that Mrs. W. would not accept or follow through with a referral to a psychiatrist. Nor would she be likely to accept or take antipsychotic medications, particularly if she clearly understood what the medications were for. He thought that those two were likely given her suspiciousness of new people and given both her and the family’s reluctance to discuss mental health issues in family members. Furthermore, he was concerned that there was a very good chance that such a referral or prescription might result in her dropping out of treatment at the primary care clinic and might impede her developing a (relatively) trusting relationship with her new PCR. He felt that it was important for her to develop a relationship with the PCR and with other staff at the primary care clinic. Since she had been living with and functioning independently despite having these symptoms for her entire adult life, the social worker recommended that the PCR keep an eye on her at present, hold off more aggressive treatment of the symptoms, and monitor the symptoms periodically in case her situation changed or the symptoms worsened. Then at that time, they could revisit a referral or treatment that would be based on a better, and hopefully, more trusting relationship. He also recommended that Mrs. W.’s son continue seeing her at about the same frequency as he had been but to notify the PCR or the social worker if he noticed any changes in Mrs. W.’s behavior, her suspiciousness and hallucinations, or her living situation. He suggested that, as they got to know Mrs. W. and her son better, they should consider providing some psychoeducation on psychotic symptoms to him or to Mrs. W. and him together.
Document Date: September 9, 2009
Assessment Instruments
- Mini-International Neuropsychiatric Interview (MINI). Register and download paper and pencil version free at: http://www.medical-outcomes.com/index/cloud. The MINI is available in several languages. The MINI includes both a two-page screen and a full differential diagnostic interview for the most important DSM-IV-TR Axis I disorders. The MINI is similar in structure to the Structured Clinical Interview for DSM-IV or SCID, in that it has probe questions, skips, and a format for noting responses.
- John A. Hartford Institute for Geriatric Nursing Try This. Try This: Best Practices in Nursing Care to Older Adults is a series of assessment tools to provide knowledge of best practices in the care of older adults. Includes a general assessment tool (SPICES), the Katz Index of Independence in Activities of Daily Living; Mental Status Assessment of Older Adults (Mini-Cog), and the Geriatric Depression Scale (GDS) in English or Spanish. http://www.hartfordign.org/practice/try_this/
- Neurotransmitter.net Psychiatric Rating Scales Index. This link takes you to a list of conditions. Selecting one of these conditions takes you to a list of assessment instruments, many of which can be downloaded and used in your practice, others take you to a link to contact the instrument developer about use. (Includes scales for Anxiety, Depression, Parkinson’s Disease, Alzheimer’s Disease and Dementia, Schizophrenia, among others.) http://www.neurotransmitter.net/ratingscales.html
Information, Self-help, web-links.
- Medline Plus Schizophrenia. Medline Plus is a service of the National Library of Medicine and the National Institutes of Health. This site lists a number of resources on schizophrenia including articles, directories, glossaries, links to associations, and both disorder-specific and population-specific information. http://www.nlm.nih.gov/medlineplus/schizophrenia.html
- AARP Ageline Database. AgeLine abstracts the literature of social gerontology as well as aging-related research from psychology, sociology, social work, economics, public policy, and the health sciences. It covers aging-related issues for professionals in aging services, health, business, law, and mental health. AgeLine also includes selected consumer content. AgeLine summarizes journal articles, books and chapters, research reports, dissertations, gray literature, and educational videos from many publishers and organizations, including AARP. Links to full text or ordering options are included wherever possible. http://www.ebscohost.com/academic/ageline
- National Alliance on Mental Illness (NAMI). NAMI is nation’s largest grassroots organization for people with mental illness and their families. Founded in 1979, NAMI has affiliates in every state and in more than 1,100 local communities across the country. NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life for persons of all ages who are affected by mental illnesses. This site provides information on schizophrenia, antipsychotic medications, and links to other resources including discussion groups, treatment recommendations, and support. http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23036&lstid=327
Document Date: September 9, 2009
Download this PowerPoint for Chapter 4 of the Mental Health Resource Review.
Document Date: September 9, 2009
Zvi D. Gellis, PhD. University of Pennsylvania
Kim McClive-Reed, PhD, University at Albany
Stanley G. McCracken, PhD, University of Chicago
Depression in Older Adults With Dementia
Profile
- Purpose: To teach master’s-level direct practice social work students about depression in older adults with dementia.
- Audience: Masters-level social work students.
- Audience Size: Maximum 40.
Content
- Core Values
- To recognize and treat older adults as people first.
- To understand that older adults have goals and desires just like younger people, which may include independent living, meaningful and enjoyable activities, and mature relationships, and that they also have the capacity to learn, grow, and achieve these goals.
- To foster and promote the understanding that older adults deserve courtesy, respect, and dignity in all interactions.
- To provide a safe, caring environment in which to live.
- To advocate for evidence-based interventions and services that are sensitive to diversity.
- To attempt to change the environment to meet the resident’s needs.
- To make every effort to support attempts to build and maintain skills and promote independence.
- Informational Competencies. At the end of this module, students will know the following:
- Cognitive impairment in older adults exists on a continuum from normal age-associated memory decline (AAMD) to mild cognitive impairment (MCI) to dementia.
- Dementia is a constellation of symptoms caused by diseases and disorders that affect the brain, including strokes, Alzheimer’s disease (AD), Parkinson’s disease (PD), toxin exposure, infectious diseases, nutritional deficiencies, and others.
- Dementia may be either reversible or irreversible and either progressive or nonprogressive, depending on the cause of the dementia.
- Why it is important to assess and treat depression in individuals with dementia.
- The behavioral and psychological symptoms of dementia (BPSD) and the two clusters these symptoms fall into.
- The common depression screening protocol consists of the Mini Mental State Exam and either the Cornell Scale for Depression in Dementia (CSDD) or the Short Geriatric Depression Scale (GDS).
- The GDS should be used for patient with scores of 15 to 23 on the MMSE, and the CSDD should be used if the patient scores below 15 on the MMSE.
- If the GDS is 6 or greater or the CSDD is 11 or greater, the primary health care provider should be notified for further evaluation and/or treatment for clinically significant depression.
- Apathy has been found to be related to a higher frequency of both minor and major depression.
- Depression may be a risk factor for progression from MCI to dementia.
- Expert consensus recommends selective serotonin reuptake inhibitors (SSRIs) as the preferred pharmacological treatment for depression in patients with dementia.
- Physical and cognitive frailty, drug interactions, and polypharmacy may help provoke depressive and other symptoms in some patients with dementia and patients may be susceptible to adverse effects.
- Clinical guidelines specify the use of non-pharmacological treatments for the BPSD before the use of pharmacological treatments.
- Scientific evidence for the effectiveness of emotion-oriented therapies (Reality Orientation, Validation Therapy, and Reminiscence Therapy) is weak, and further research is needed.
- Scientific evidence for cognitive and behavioral therapies is somewhat stronger. Results of a few large randomized trial studies were consistent and showed benefits, compared to control groups, and the outcome effects on depression reduction were maintained over time.
- Interventional Competencies. At the end of this unit, trainees will be able to:
- Conduct an MMSE.
- Conduct a depression screening starting with a MMSE followed by either the GDS or the CSDD.
- Based on the results of their depression screening, make an appropriate recommendation for either additional assessment and treatment of depression or a follow up depression screening.
Time Needed:
1-2 hours, depending on class size and time spent on exercises.
Training Format:
Didactic lecture, exercises.
Equipment
Chalkboard, flipchart, or dry erase board with markers.
LCD projector & laptop computer.
Slides
PowerPoint slides (see separate file).
Review of the Literature
Review of the literature (see separate file).
Dementia and Behavioral and Psychological
Symptoms of Dementia
- Cognitive impairment in older adults exists on a continuum from normal age-associated memory decline (AAMD) to mild cognitive impairment (MCI) to dementia.
- Dementia is a constellation of symptoms caused by diseases and disorders that affect the brain, including stroke, Alzheimer’s disease (AD), Parkinson’s disease (PD), toxin exposure, infectious diseases, nutritional deficiencies, and others. Dementia may be either reversible or irreversible and either progressive or nonprogressive depending on the cause.
- AD is believed to be the most common type of dementia (50-70%), followed by vascular dementia (VaD) (> 20%) and dementia with Lewy bodies (DLB) (< 20%); the remainder (e.g., frontotemporal dementia [FTD], dementia associated with PD) account for less than 10%. About 30% of people with AD also have VaD.
- Dementia involves progressive loss of memory and other cognitive functions such as problem-solving and emotional control. As dementia progresses, abilities to independently perform instrumental and basic activities of daily living are generally impaired.
Cognitive impairment in older adults exists on a continuum beginning with normal age-associated memory decline (AAMD), also called age-associated memory impairment (AAMI) or cognitive impairment no dementia (CIND). The next stage, which is earliest diagnosable stage of dementia, is called mild cognitive impairment (MCI). Individuals with MCI experience mild impairment of memory, concentration, and occupational performance (Agronin, 2008; See Table 1. Global Deterioration Scale). Mini-mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores of 24-27 (out of 30) are common in people with MCI. Dementia refers to a spectrum of brain disorders, all of which involve cognitive impairment but vary widely in terms of cause, course, and prognosis. The essential feature of dementia is the development of multiple cognitive deficits that include memory impairment and at least one of the following cognitive disturbances: aphasia (deterioration of language function), apraxia (impaired ability to execute motor activities despite intact motor abilities, sensory function, and comprehension of the required task), agnosia (failure to recognize or identify objects despite intact sensory function), or a disturbance in executive functioning (ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior). Memory impairment is required to make the diagnosis of a dementia and is a prominent early symptom (DSM-IV-TR, American Psychiatric Association [APA], 2000).
- Worldwide, dementia is one of the most disabling health conditions; it is the fourth leading cause of disease burden among adults > 60.
- 24.3 million persons had dementia in 2005, with 4.6 million new cases reported annually; the number is expected to double every 20 years.
An estimated 24.3 million people had dementia in 2005, with 4.6 million new cases of dementia occurring annually. The number of people affected is expected to double every 20 years (Ferri et al., 2005). Alzheimer’s and other dementias ranked as the 4th leading cause of disease burden in adults age 60 and older worldwide, outranked only by heart disease, arthritis, and chronic obstructive pulmonary disease (World Health Organization, 2003).
- The most common instrument for dementia screening is the Mini-Mental State Examination (MMSE). The Mini-Cog is a briefer screen that is often used in primary care settings.
A variety of instruments are used to screen for dementia. The most common of these is the Mini-Mental State Examination (MMSE, Folstein et al. 1975). The MMSE is a 30-point scale that assesses orientation, memory registration and recall, attention, calculation, language, and constructional ability. It typically takes 5-10 minutes to complete, is relatively simple to administer, and provides a relatively high degree of sensitivity and specificity for dementia. Among its disadvantages are that differences in administration and scoring can lead to inconsistent results. It also contains an education and language/cultural bias, and at 10 minutes, it is too long to be practical for use in primary care settings in which physicians have limited time to administer a screening test (Brodaty, Withall, Altendorf, & Sachdev, 2007). The Mini-Cog (Borson et al., 2000) can be administered in under 5 minutes, has similar psychometric properties to the MMSE, and has become popular in primary care settings. (See Table 2 for links to the MMSE and Mini-Cog).
- Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms of dementia, affect up to 95% of those with dementia during the course of the illness. The appearance of BPSD are often the first signs that the illness is progressing.
- BPSD fall into two clusters, (1) behavioral and (2) psychological. Behavioral symptoms are usually identified through observation of the client and include physical aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing, and shadowing. Psychological symptoms, primarily assessed through interviews with clients and caregivers, include depressed mood, anxiety, hallucinations, and delusions.
- BPSD reduce patients’ quality of life, may accelerate cognitive and functional decline, are associated with increased mortality, increase the risk for institutionalization, significantly increase caregiver burden and stress, and are associated with increased rates of depression in caregivers.
- Behavioral symptoms are generally more prevalent in moderate to severe dementia. Psychological symptoms, such as depression, may cause greater distress to the client as they develop insight into the impact of dementia on their futures.
BPSD have important implications for the prognosis of dementia in older adults. BPSD reduce patients’ quality of life, may accelerate cognitive and functional decline, and are associated with increased mortality (Amore, Tagariello, Laterza, & Savoia, 2007; Teng, Lu, & Cummings, 2007; Fitzpatrick, Kuller, Lopez, Kawas, & Jagust, 2005; Potter & Steffens, 2007). Furthermore, these symptoms significantly increase caregiver burden and stress, and are associated with increased rates of depression in caregivers (Black & Almeida, 2004). They have also been found to increase the risk for institutionalization (Coehlo, Hooker, & Bookman, 2007). Finally, management of BPSD has been estimated to account for approximately one-third of the total cost of dementia care (Beeri, Werner, Davidson, & Noy, 2002).
Prevalence, Comorbidity, and Significance of Depression in Dementia
- Depressive symptoms are very common in MCI and across the various types of dementia. The reported prevalence of depression in older patients with dementia ranges from 30% to 96%; moderate to high rates of depression or its symptoms are consistently reported for persons with MCI.
- The wide range of prevalence reported for depression in dementia is due to several factors: focus on symptoms versus specifically defined depressive disorders, underlying cause of dementia, stage of the illness, place of residence of the older adult, and instrument used to assess depression.
- Consequences of comorbidity of depression and MCI/dementia:
- Greater impairments in activities of daily living.
- Greater impairment of functional performance, above and beyond the effects of cognitive impairment alone.
- Increased level of other BPSD.
- Higher rates of institutionalization of older adults, likely due to the negative impact on caregivers.
- Higher cost of treatment.
The reported prevalence of depression in older patients with dementia ranges from 30% to 96% (Amore et al., 2007; Kales, Chen, Blow, Welsh, & Mellow, 2005; Starkstein, Jorge, Mizrahi, & Robinson, 2005), and moderate to high rates of depression or its symptoms are consistently reported for persons with MCI (i.e., 36% by Palmer et al., 2007; 63.3% by Solfrizzi et al., 2007; 39% by Hwang, Masterman, Ortiz, Fairbanks, & Cummings, 2004). The width of the prevalence range for depression in dementia is due to several factors, including the following: differences in researchers’ focus on symptoms versus specifically defined depressive disorders; diverse study samples varying in causes of dementia, stage of illness, country of residence, and placement of older patient; and instrument variation used to assess depressive symptoms and disorders.
Assessment of Depression in Dementia
- Assessment of depression in individuals with dementia is difficult because long-term care residents with dementia present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect).
- Current guidelines recommend screening for depression at least every 6 months.
- The depression screening assessment consists of (a) the MMSE, and either (b) the Cornell Scale for Depression in Dementia (CSDD), or the (c) Short Geriatric Depression Scale (GDS-15 item). Use the GDS for individuals scoring 15 to 23 on the MMSE and the CSDD if the individual scores below 15. The CSDD collects information from both the client and a caregiver or other reliable informant. Clients who score >6 on the GDS or >11 on the CSDD should be referred to the primary care provider for further evaluation and/or treatment for depression.
- If the older adult with dementia does not screen positive for depressive symptoms, the individual should be reevaluated in 1 month if clinically warranted, otherwise, 6 months later.
- Interview caregivers/informants on behalf of the individual with moderate to severe dementia.
- Attend to the biopsychosocial factors during assessment.
- Treatment of depression may improve both dementia and depression and may increase the time an older person lives at home prior to a needed nursing home placement.
Detection and assessment of depression in older adults with dementia can be challenging. Many long-term care residents with dementia present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect) (Gauthier, 2003; Riccio, Solinas, Astara, & Mantovani, 2007). Based on current evidence-based practice guidelines, screening for depression should occur at least every 6 months (Brown, Raue, & Halpert, 2007). The depression screening assessment consists of the (a) Mini Mental State Exam (MMSE) used frequently to screen for dementia, and either the (b) Cornell Scale for Depression in Dementia (CSDD; Alexopoulos, Abrams, Young, & Shamoian, 1988), or the (c) Short Geriatric Depression Scale (GDS-15 item; Sheik & Yesavage, 1986) depending on patient cognitive functioning. The guidelines suggest using the GDS for patients scoring 15 to 23 on the MMSE, or the CSDD if the patient scores below 15 on the MMSE. The CSDD collects interview information from both the patient and the informant. If patients score 6 or greater on the GDS, or 11 or greater on the CSDD, the primary health care provider should be notified for further evaluation and/or treatment for clinically significant depression (Brown et al., 2007). If the older adult with dementia does not screen positive for depressive symptoms, the guidelines suggest that the individual be reevaluated in 1 month if clinically warranted, otherwise, 6 months later. Interviewing caregivers and other reliable informants on behalf of the individual with moderate to severe dementia is also recommended (American Geriatrics Society & American Association of Geriatric Psychiatry, 2003). Attention needs to be paid to the biopsychosocial factors during assessment to obtain a clear picture of the patient.
Course and Presentation of Depression in Dementia
- Several studies indicate that depression in older adults with dementia tends to increase as cognitive decline in dementia progresses. Other research indicates higher prevalence rates of depression in the early stages of dementia with diminished prevalence as cognitive function becomes severely impaired and insight is lost. This apparent drop in prevalence may be due to differences in the presentation of depression in the later stages of dementia.
- Apathy has been found to be related to a higher frequency of both minor and major depression.
Lopez and colleagues (2003) examined the relationship between major depression and other observed psychiatric symptoms across mild, moderate, and severe stages of cognitive impairment. They found that fewer observed symptoms were associated with diagnosed depression as the stage of dementia increased. For example, confirmed depression in those with mild dementia was associated with anhedonia, sleep disturbance, depressed mood, and hopelessness, whereas moderate dementia and depression were associated with these symptoms, minus the anhedonia, and severe dementia with depression was associated only with hopelessness.
Another explanation of the differences in findings on the prevalence rates of depression over the course of dementia may be disagreement on whether and how to distinguish apathy from depression. Researchers administered a structured interview (developed from caregiver ratings) to measure apathy and depression separately. They reported that 12% met distinct criteria for both apathy and depression, 7% met criteria for apathy only, and 31% met criteria for depression only (Starkstein, Ingram, Garau, & Mizrahi, 2005). Supporting their argument that the two constructs were different, apathy, but not depression, was significantly associated with more severe cognitive deficits. However, a later study found that apathy was related to a higher frequency of both minor and major depression, with apathy at baseline significantly predicting depression at follow-up evaluations, findings that support a relationship between the two constructs (Starkstein, Jorge, Mizrahi, & Robinson, 2006).
Consequences of Depression in Older Adults with Dementia
- Studies have identified pre-existing depression as a predictor or risk factor for subsequent dementia and have estimated that persons experiencing depression have approximately double the risk of developing dementia that those without a prior history of depression have.
- Depression may be a risk factor for progression from MCI to dementia.
- Depression in persons with MCI or dementia has been linked with increased severity of cognitive deficits.
- Co-morbid cognitive impairment and depression have been associated with several other negative consequences, including an increased risk of death and reduced quality of life reports from dementia patients and their caregivers.
- Although suicide attempts have been observed in less than 1% of dementia patients, suicidal ideation, intent, passive death wishes, and feelings that life is not worth living have been reported in 1% to 42% of dementia patients, particularly in those suffering from depression.
Depression may be a risk factor for progression from MCI to dementia. The occurrence of depression in persons with MCI or dementia has also been linked to increased general severity of cognitive deficits (Nakaaki et al., 2007). Co-morbid cognitive impairment and depression have also been associated with several other negative consequences, including an increased risk of death (Sutcliffe et al., 2007). Although suicide attempts have been observed in less than 1% of dementia patients, suicidal ideation, intent, passive death wishes, and feelings that life is not worth living have been reported in 1% to 42% of dementia patients, particularly in those suffering from depression (Thompson, Herrmann, Rapoport, & Lanctot, 2007; Tsai, Tsai, Yang, & Hwang, 2007).
Treatment of Depression in Dementia
Pharmacotherapy
- Depression is more likely to respond to medication than other BPSD.
- Pharmacological treatment of depression in dementia presents challenges due to the high level of comorbidity, use of multiple medications with the accompanying risk of drug interactions, physical and cognitive frailty, and impaired ability to communicate among older adults with dementia.
- Antidepressants.
- Older adults with depression in dementia respond to tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).
- Significant declines in cognitive scores are seen in individuals taking TCAs.
- At this time SSRIs are the preferred treatment for depression in older adults with dementia.
A recent meta-analysis (Thompson et al., 2007) reviewed treatment of depression with tricyclic antidepressants (TCA; imipramine and clomipramine), and SSRIs (sertraline and fluoxetine) in patients with dementia. The findings indicated that patient treatment response and remission was superior to placebo in the combined sample from all studies, but cautioned that significant declines in cognitive scores occurred during the use of TCAs. Other reviews (Buhr & White, 2006; Sink, Holden, & Yaffee, 2005) provide further support for positive effects of treatment with various antidepressants (including sertraline, fluoxetine, citalopram, trazodone, and moclobemide) on depression in dementia, with citalopram and sertraline being the most commonly prescribed (Caballero, Hitchcock, Beversdorf, Scharre, & Nahata, 2006; Daiello, 2007; Starkstein & Mizrahi, 2006). Alexopoulos, Jeste, Chung, Carpenter, Ross, and Docherty (2005) constructed an expert consensus response after surveying 50 experts in dementia from North America on preferred, alternate, and unacceptable treatment choices for BPSD. The general consensus was that SSRIs were the preferred pharmacological treatment for depression in patients with dementia.
- Antipsychotics.
- While a number of different antipsychotic drugs have been used with varying degrees of success in treating BPSD, including depression, older adults with dementia are at high risk for developing extrapyramidal symptoms (EPS), such as Parkinsonism and tardive dyskinesia.
- Atypical antipsychotic drugs, such as risperidone and olanzapine, have significant, though modest, effects and reduced risk of EPS at lower doses. However, there have been reports of increased risk of strokes and mortality with these drugs, though there is controversy about the degree of this risk or even whether there is any.
Different classes of antipsychotics have also been used to treat depression with varying degrees of success (Lee et al., 2004; Snowdon, Sato, & Roy-Byrne, 2003). However, older adults with dementia taking haloperidol and other “typical” antipsychotics have been found to be at significant risk of extrapyramidal symptoms (EPS), including parkinsonism and tardive dyskinesia (Sink et al., 2005). Atypical antipsychotics such as risperidone and olanzapine have been shown to have significant, though modest, effects, and fewer adverse effects than typical antipsychotics at lower doses (Herrmann & Lanctot, 2007; Sink et al., 2005). However, since both risperidone and olanzepine have been associated with an increased risk of stroke and associated mortality, subsequent safety warnings have led providers to be cautious and somewhat restrictive about their use in older patients with dementia. Yet, a recent meta-analysis (Katz et al., 2007) concluded that although cerebrovascular events and mortality observations across trials were more frequent in risperidone-treated groups, the frequency did not differ significantly from that in placebo groups.
- Other medications.
- Cholinesterase inhibitors are used to treat both the cognitive deficits of dementia and BPSD. Positive effects have been found for rivastigmine in patients with a wide range of dementia, and apathy and anxiety are among the behavioral domains demonstrating the most consistent positive response.
- Memantine, a drug that affects the glutamate neurotransmitter system, has been found to improve cognitive functioning as well as psychological symptoms of dementia (such as depression).
- Anticonvulsant drugs, such as valproate and lamotrigene, have yielded some positive findings, though research, to date, has been insufficient to support conclusions about the effectiveness of this class of medications.
- Finally, some research findings have indicated the effectiveness of a ginko biloba extract for improving cognitive functioning and enhancing mood among older adults with dementia and BPSD, though there continues to be controversy about the effectiveness of this intervention.
Cholinesterase inhibitors, which increase levels of acetylcholine, have been used to target cognitive deficits and BPSD with some success, particularly in patients with mild to moderate dementia (Birks, 2006; Garcia-Alloza, 2005). A recent review of the literature on the effects of rivastigmine on BPSD reports that positive effects have been found for patients with a wide range of dementia, and that apathy and anxiety are among the behavioral domains demonstrating the most consistent positive response (Figiel & Sadowsky, 2008).
A recent review and meta-analysis of the research on memantine for the treatment of psychological symptoms (e.g., depression) of dementia showed small but significant improvements with limited adverse effects (Maidment et al., 2008).
At least one clinical trial of valproate resulted in significant improvement in melancholic and sorrowful behaviors (Sival, Haffmans, Jansen, Duursma, & Eikelenboom, 2002), but the results of other small trials are contradictory (Sink et al., 2005). Preliminary studies of another anticonvulsant, lamotrigine, in elderly patients with dementia noted improvement in symptoms of agitation and depression (Sajatovic, Ramsay, Nanry, & Thompson, 2007). Studies provide some support for the theory that Ginkgo biloba special extract EGb 761 enhances cognitive functioning and stabilizes mood in cognitively impaired elderly subjects (Woelk, Arnoldt, Kieser, & Hoerr, 2007). A review of the research (Birks & Grimely-Evans, 2007) concluded that the evidence that the extract has predictable and clinically significant benefit for older people with dementia or cognitive impairment is inconsistent and unconvincing. However, a recent trial of this extract involving patients with dementia found that compared to controls, those taking the extract experienced improvements in apathy and depression (Scripnikov, Khomenko, & Napryeyenko, 2007).
Non-pharmacological treatments for depression in dementia
- Clinical guidelines specify the use of non-pharmacological treatments for BPSD before pharmacological treatments are tried.
As well as avoiding potential effects of polypharmacy, drug interactions, or exacerbation of comorbid conditions, non-pharmacological treatments may improve the quality of life for the patient with dementia above and beyond the reduction of depression (Burgio & Fisher, 2000; Cohen-Mansfield, 2005; Woods, 2004).
Emotion-oriented therapies
- Reality Orientation groups were originally intended to reduce confusion by giving repeated orientation clues, e.g., the time of day, date, and season, but this was only partially successful. Research has suggested that the main benefits were the stimulation of the social group and the positive impact on staff, who acquired a better knowledge of the residents and their earlier lives and interests.
- Reminiscence Therapy encourages persons with dementia to talk about their pasts, and may utilize audiovisual aids such as old family photos and objects to retrieve positive events and emotions. Reminiscence provides persons with dementia a chance to interact positively with others; it can enhance an individuals' sense of identity, sense of worth, or general well-being, and may also stimulate memory processes.
- Validation Therapy is a type of psychosocial intervention for older adults with dementia. Basically, a therapist accepts the disorientation of a person with dementia and validates his/her feelings (Feil, 2002). This intervention is based on the assumption that individuals return to unfinished conflicts in their past, providing a background for meaningful conversations addressing their feelings.
- Scientific evidence for the effectiveness of emotion-oriented therapies (Reality Orientation, Validation Therapy, and Reminiscence Therapy) is weak, and further research is needed.
Livingston and colleagues (2005) reported the results of 11 studies consisting of randomized and quasi-experimental designs on Reality Orientation. The largest controlled trial (N=57 subjects) demonstrated no differences between Reality Orientation and active hospital ward orientation (Hanley, McGuire, & Boyd, 1981). The smaller sample nonrandomized studies mostly showed benefits of Reality Orientation in decreasing depressive symptoms or delaying admission to an institution. The current research does not offer clear evidence of its benefits for older adults with dementia.
Two reviews that included information on Reminiscence Therapy reported potentially positive effects on depressed mood in patients with dementia, but caution that most trials were small or otherwise methodologically questionable and therefore the evidence is weak and inconclusive (Douglas, James, & Ballard, 2004; Livingston et al., 2005).
Neal and Briggs (2003) reviewed trials of Validation Therapy and reported that only one study (Toseland et al., 1997) showed a trend towards improvement of depression a year after completing therapy, but the finding was not statistically significant. Another recent study using Validation Therapy in a group format found similar results (Deponte & Missan, 2007). The empirical evidence for this therapy for depression in dementia is weak and unconvincing.
Cognitive and behavioral therapies
- Behavioral interventions.
- Behavior therapy requires a period of detailed assessment in which the personal triggers, behaviors, and reinforcers are identified and their relationships made clear to the patient.
- While a number of studies have demonstrated the effectiveness of behavior therapy for behavioral symptoms of dementia, there is limited support for it effectiveness in reducing the symptoms of depression.
- Cognitive behavioral interventions.
- Several small studies and case reports have demonstrated the effectiveness of group and individual cognitive behavioral techniques, such as distraction, relaxation, and cognitive restructuring, in reducing symptoms of depression in individuals with early stages of dementia. However, there have been no large scale trials of cognitive behavioral-therapies (CBT) in this population.
- Scientific evidence for the effectiveness of cognitive and behavioral therapies is somewhat stronger than emotion-oriented therapies in reducing depressive symptoms. As described below, results of a few larger randomized trial studies were consistent and showed benefits for the treatment groups compared to control groups, and the effects on depression reductions were maintained over time.
A recent systematic review examined 20 studies using behavioral management techniques for treating depressive (n= 3 studies) and neuropsychiatric symptoms (17 studies) in older adults with dementia (Livingston et al., 2005). Of the three evaluating depression outcomes, one large randomized controlled trial showed significant improvement in depressive symptoms at post-treatment and at 6-month follow-up in one large randomized controlled trial showed significant improvement in depressive symptoms immediately post-treatment and at 6-month follow-up examination in two treatment conditions: (1) one emphasizing patient pleasant events and one emphasizing caregiver problem solving, as compared to treatment as usual and waitlist control conditions (Teri, Logdson, Uomoto, & McCurry, 1997). The two smaller randomized trials also demonstrated significant reductions in behavioral symptoms compared to usual primary care (Benedict et al., 2000; Suhr, Anderson, & Tranel, 1999). However, no significant effects were found on depression (Benedict et al., 2000).
Hyer and colleagues (1990) compared the effectiveness of a 12-week group psychotherapy, in a cognitive behavioral format, to usual care in a small sample of 22 residents. At post-treatment, depression scores had decreased in the treatment group but not in the control group. Koder (1998) discussed two case reports in which cognitive behavioral therapy was offered using techniques such as relaxation, distraction, and cognitive restructuring. Teri, Curtis, Gallagher-Thompson, and Thompson (1994) reported positive findings from a clinical trial of CBT with people in the early stages of Alzheimer’s disease. Individual and group CBT has also been used by other researchers with some favorable results (Kipling, Bailey, & Charlesworth, 1999).
There are several limitations to the literature on non-pharmacological interventions. First, most research studies have focused on behavioral and not depressive symptom outcomes. Second, the diversity of sample elderly populations makes it difficult to compare across studies. Third, the majority of studies lack a description of intervention protocols or manuals making it difficult to understand, analyze, or replicate the treatment components. Finally, the inconsistency of follow-up protocols across studies provides further barriers to determining long-term effects of the intervention.
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Document Date: September 9, 2009
Zvi D. Gellis, PhD. University of Pennsylvania
Kim McClive-Reed, PhD, University at Albany
Stanley G. McCracken, PhD, University of Chicago
Depression in Older Adults With Dementia
This evidence-based review of the literature on depression disorders among older adults with dementia focuses on prevalence, clinical recognition, assessment, and treatment. A search of the empirical literature was undertaken to determine the extent of the problem and the effectiveness of various pharmacological and non-pharmacological treatments.
Dementia is a constellation of symptoms caused by diseases and disorders that affect the brain, including strokes, Alzheimer’s disease (AD), Parkinson’s disease (PD), and others. Dementia involves progressive loss of memory and other cognitive functions such as problem-solving and emotional control. The earliest diagnosable stage of dementia is referred to as mild cognitive impairment (MCI). As dementia progresses, abilities to independently perform instrumental and basic activities of daily living are generally impaired.
Worldwide, dementia is one of the most disabling health conditions. An estimated 24.3 million people had dementia in 2005, with 4.6 million new cases of dementia occurring annually. The number of people affected is expected to double every 20 years (Ferri et al., 2005). Alzheimer’s and other dementias ranked as the fourth leading cause of disease burden in adults age 60 and older worldwide, outranked only by heart disease and chronic obstructive pulmonary disease (World Health Organization, 2003). Generally, AD is believed to be the most common type of dementia, followed by vascular dementia (VaD), frontotemporal dementia (FTD), dementia associated with PD, and dementia with Lewy bodies (DLB).
Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms of dementia, affect up to 95% of those with dementia during the course of the illness (Steinberg et al., 2006) and are frequently the first manifestation of its progress. According to classifications developed during the International Psychogeriatric Association Consensus Conference on the Behavioral Disturbances of Dementia (2002), BPSD fall into two clusters: (1) behavioral and (2) psychological. Behavioral symptoms are usually identified through observation of the patient, and include physical aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing, and shadowing. Psychological symptoms, primarily assessed through interviews with patients and caregivers, include depressive mood, anxiety, hallucinations, and delusions.
BPSD have important implications for the prognosis of dementia in older adults. BPSD reduce patients’ quality of life (Amore, Tagariello, Laterza & Savoia, 2007; Teng, Lu & Cummings, 2007), may accelerate cognitive and functional decline, and are associated with increased mortality (Fitzpatrick, Kuller, Lopez, Kawas, & Jagust, 2005; Potter & Steffens, 2007). Furthermore, these symptoms significantly increase caregiver burden and stress, and are associated with increased rates of depression in caregivers (Black & Almeida, 2004). They have also been found to increase the risk for institutionalization (Coehlo, Hooker & Bookman, 2007). Finally, management of BPSD has been estimated to account for approximately one-third of the total cost of dementia care (Beeri, Werner, Davidson & Noy, 2002).
The behavioral symptoms of dementia, which may be even more apparent and distressing to observers than the psychological symptoms, are generally more prevalent in moderate to severe dementia. However, psychological symptoms such as depression may cause greater distress to the patient, especially during the earlier stages of dementia, as sufferers develop insight regarding the impact of the diagnosis on their future.
Search Strategy
This evidence-based review consists of systematic reviews, meta-analyses, other reviews of the literature, experimental, quasi-experimental designs, and case studies with older adults (65+) as participants reported in English language peer-reviewed journals. Keyword search terms included aged, elderly, geri*, older adult, long-term care, dementia, Alzheimer* depress*, mood disorder, treatment, and randomized controlled trials. Searches were conducted on the following databases: PubMed (1997-2007/December); PsychINFO (1972-2007); Ageline (1978-2007), and EbscoHost Research—Academic Search Premier (through 2007). Google Scholar was also searched using November 2007-February 2008 as the time range to identify recent publications that would not have been cited. Unpublished literature was not included in the review.
Prevalence and Comorbidity of Depression in Dementia
Depressive symptoms are very common in mild cognitive impairment and across the various types of dementia. The reported prevalence of depression in older patients with dementia ranges from 30 to 96% (Amore et al., 2007; Starkstein, Jorge, Mizrahi, & Robinson, 2005), and moderate to high rates of depression or its symptoms are consistently reported for persons with MCI (i.e., 36% by Palmer, Berger, Monastero, Winblad, Backman, & Fraitiglioni, 2007; 63.3% by Solfrizzi et al., 2007; 39% by Hwang, Masterman, Ortiz, Fairbanks, & Cummings, 2004). The wide prevalence range for depression in dementia is due to several factors including differences in researchers’ focus on symptoms versus specifically defined depressive disorders; diverse study samples varying in causes of dementia, stage of illness, country of residence, and placement of older patient; and instrument variation used to assess depressive symptoms and disorders.
Comorbidity of depression in older persons with MCI or probable AD has been associated with greater impairments in activities of daily living (Teri et al., 1999). Likewise, increasing cognitive impairment appears to interact with the presence of depressive symptoms to further impair functional performance, above and beyond the effects of cognitive impairment alone (Schultz, Hoth, & Buckwalter, 2004). The presence of depression in cognitively impaired persons also appears to increase the level of other BPSD. Comorbid depression and dementia are associated with higher rates of institutionalization of older adults, likely due to the negative impact on caregivers (Black & Almeida, 2004; Potter & Steffens, 2007). Untreated depression has also been related to higher treatment costs for persons with dementia (Hemels, Lanctot, Iskedjian, & Einarson, 2001).
Assessment of Depression in Dementia
Detection and assessment of depression in older adults with dementia can be challenging for the clinician. Many long-term care residents with dementia present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect) (Gauthier, 2003). Based on current evidence-based practice guidelines, screening for depression in this population should occur at least every 6 months (Brown, Raue, & Halpert, 2007) (Level C). The depression screening assessment consists of the (a) Mini Mental State Exam (MMSE; Folstein et al., 1975) used frequently to screen for dementia, and either the (b) Cornell Scale for Depression in Dementia (CSDD; Alexopolous, Abrams, Young, & Shamoian, 1988), or the (c) Short Geriatric Depression Scale (GDS-15 item; Sheik & Yesavage, 1986) depending on patient cognitive functioning (Brown et al., 2007). The guidelines suggest using the GDS for patients scoring 15 to 23 on the MMSE or the CSDD if the patient scores below 15 on the MMSE. The CSDD collects interview information from both the patient and an informant. If patients score 6 or greater on the GDS, or 11 or greater on the CSDD, the primary health care provider should be notified for further evaluation and/or treatment for clinically significant depression (Brown et al., 2007). If the older adult with dementia does not screen positive for depressive symptoms, the guidelines suggest that the individual be reevaluated in 1 month if clinically warranted, otherwise, 6 months later. It is also recommended to interview caregivers and other reliable informants on behalf of the individual with moderate to severe dementia (American Geriatrics Society & American Association of Geriatric Psychiatry, 2003). Attention needs to be paid to the biopsychosocial factors during assessment to obtain a clear picture of the patient. Assertive outpatient and community-based treatment of depression may also improve the course of coexisting dementia and depression and lengthen the time the patient can remain at home before nursing home placement.
A recent study focused on specific factors that might contribute to nursing home placement by examining the detection and course of coexisting dementia and depression (CDD) in elderly patients compared with patients with either disorder alone (Kales, Chen, Blow, Welsh, & Mellow, 2005) (Level C). This was a 1-year prospective study comparing outcomes among 82 elderly male veterans receiving inpatient and outpatient treatment. Subjects were recruited and reassessed at 3, 6, and 12 months after baseline. This study found lower rates of depression detection by treating (i.e., non-study) physicians in CDD patients. Only 35% of the CDD group were correctly diagnosed and received adequate treatment. The CDD group had significantly higher levels of functional impairment when compared to the dementia-only group. The CDD subjects used nursing home care at significantly higher rates. The investigators concluded that undetected, untreated, or inadequately treated depression may result in higher rates of nursing home placement in patients with dementia due to an increase in functional disability.
Course and Presentation of Depression in Dementia
Studies have identified pre-existing depression as a predictor or risk factor for subsequent dementia and estimated that persons experiencing depression have approximately double the risk of developing dementia that those without a prior history of depression have (Palmer et al., 2007; Teng et al., 2007). Although several studies indicate that the risk of depression in older adults with dementia tends to increase as cognitive decline in dementia progresses (Riccio, Solinas, Astara, & Mantovani, 2007; Solfrizzi et al, 2007; Steinberg et al., 2007; Teri et al., 1999), other research indicates a curvilinear, rather than linear, relationship between the symptoms of depression and the worsening of dementia (Bierman, Comijs, Jonker, & Beekman, 2007; Starkstein, Mizrahi, & Garau, 2005; Lopez et al., 2003). Participants in these studies appear to exhibit higher prevalence rates of depression in the early stages of dementia, but these disorders seem to diminish in reported prevalence as cognitive function becomes severely impaired and insight is lost. Yet, this apparent drop in prevalence may be due to differences in the presentation of depression in the later stages of dementia.
Lopez and colleagues (2003) examined the relationship between major depression and other observed psychiatric symptoms across mild, moderate, and severe stages of cognitive impairment. They found that fewer observed symptoms were associated with diagnosed depression as dementia increased. For example, confirmed depression in those with mild dementia was associated with anhedonia, sleep disturbance, depressed mood, and hopelessness, whereas moderate dementia and depression were associated with these symptoms, minus anhedonia, and severe dementia with depression was associated only with hopelessness. Another explanation of the differences in findings on the prevalence rates of depression and over the course of dementia may be disagreement among clinicians and researchers on whether and how to distinguish apathy from depression.
To investigate this further, researchers administered a structured interview intended to measure apathy and depression separately to 150 AD patients (Starkstein, Ingram, Garau, & Mizrahi, 2005). They reported that 12% met distinct criteria for both apathy and depression, while 7% met criteria for apathy only, and 31% met criteria for depression only. Supporting their argument that the two constructs were different, apathy, but not depression, was significantly associated with more severe cognitive deficits. However, in a later study, Starkstein, Jorge, Mizrahi, and Robinson (2006) found that apathy was related to a higher frequency of both minor and major depression, with apathy at baseline significantly predicting depression at follow-up evaluations, findings that support a relationship between the two constructs.
Consequences of Depression in Older Adults with Dementia
The occurrence of depression in older adults with MCI or dementia can lead to a number of negative outcomes. Depression may be a risk factor for progression from MCI to dementia. The occurrence of depression in persons with MCI or dementia has also been linked with increased general severity of cognitive deficits (Nakaaki et al., 2007). Co-morbid cognitive impairment and depression have also been associated with several other negative consequences, including increased risk of death (Sutcliffe et al., 2007). Although suicide attempts have been observed in less than 1% of dementia patients, suicidal ideation, intent, passive death wishes, and feelings that life is not worth living have been reported in 1% to 42% of dementia patients, particularly in those suffering from depression (Thompson, Herrmann, Rapoport, & Lanctot, 2007; Tsai, Tsai, Yang, & Hwang, 2007). Depression has also been associated with reduced quality of life reports from dementia patients and their caregivers (Appleby, Roy, Valenti & Lee, 2007; Hancock, Woods, Challis, & Orrell, 2006; Selwood, Thorgrimsen, & Orrell, 2006; Shin, Carter, Masterman, Fairbanks, & Cummings, 2005; Vogel, Mortensen, Hasselbalch, Andersen, & Waldemar, 2006; Winzelberg, Williams, Preisser, Zimmerman, & Sloane, 2005).
Treatments
Both pharmacologic and nonpharmacologic treatment approaches have been found to be helpful in reducing depression associated with cognitive impairment and dementia among older adults. A wide variety of medications have been used, with varying degrees of success. Nonpharmacologic interventions, such as behavioral modification programs and structured activity programs, have also been found to reduce depression though with modest outcomes. Recently, newer treatments drawn from the field of complementary and alternative medicine, such as dosing with gingko biloba extract, have been used for persons with dementia with some success.
Pharmacological Treatments for Depression in Dementia
Depression is more likely than other BPSD in older adults to respond to pharmacological interventions (Herrmann & Lanctot, 2007). The neurotransmitters/receptors that have been targeted by pharmacological therapies include catecholamine receptors (i.e., serotonin and dopamine receptors), amino acid receptors (i.e., gamma-amino-butyric acid [GABA] and glutamate receptors), and cholinergic receptors (Lanari, Amenta, Silvestrelli, Tomassoni, & Parnetti, 2006).
Pharmacological treatment of depression in patients with dementia presents some unusual difficulties for the clinician. Older patients with dementia have more comorbid illnesses than non-demented peers, with approximately 60% of those with AD having 3 or more. This heightened level of comorbidity results in the use of multiple medications. Therefore, drug interactions and polypharmacy may help provoke depressive and other symptoms in some patients with dementia (Daiello, 2007). Given their physical and cognitive frailty, older adults with dementia may also be particularly susceptible to adverse effects. Since dementia patients may be less able to communicate, clinicians and caretakers must carefully observe patient’s behavior for evidence of adverse events when new medications are introduced. Prescription of new medications intended to treat depression in dementia patients should always be made using the familiar axiom for the elderly, “Start low and go slow” (Thompson et al., 2007).
Antidepressants
Antidepressants are frequently prescribed for treatment of depression in older adults with dementia. A recent meta-analysis (Thompson et al., 2007) reviewed treatment of depression with tricyclic antidepressants (TCA; imipramine and clomipramine), and selective serotonin reuptake inhibitors (SSRI; sertraline and fluoxetine) in patients with dementia. The findings indicated that patient treatment response and remission was superior to the placebo response in the combined sample from all studies, but cautioned that significant declines in cognitive scores occurred during the use of TCAs (Level B). Other reviews (Buhr & White, 2006; Sink, Holden & Yaffee, 2005) provide further support for positive effects of treatment with various antidepressants (including sertraline, fluoxetine, citalopram, trazodone, and moclobemide) on depression in dementia, with citalopram and sertraline being the most commonly prescribed (Caballero, Hitchcock, Beversdorf, Scharre, & Nahata, 2006; Starkstein & Mizrahi, 2006) (Level A). Case reports and small pilot studies indicate that other antidepressants, including trazadone and mirtazapine may decrease depression in patients with dementia, but no large trials have been performed in persons with dementia to date (Level D).
Antipsychotics
Different classes of antipsychotics have also been used to treat depression with varying degrees of success (Snowdon, Sato, & Roy-Byrne, 2003). However, older adults with dementia taking haloperidol and other “typical” antipsychotics have been found to be at significant risk of extrapyramidal symptoms including parkinsonism and tardive dyskinesia (Sink et al., 2005). Because of this, many clinicians have recently focused their attention on “atypical” antipsychotics such as risperidone and olanzapine (Herrmann & Lanctot, 2007; Sink et al., 2005), which have been shown to have significant, though modest, effects, and fewer adverse effects than typical antipsychotics at lower doses (Level D).
Caution should be noted as both risperidone and olanzapine have been associated with an increased risk of stroke and associated mortality, and subsequent safety warnings have somewhat limited their use in older patients with dementia. There is some disagreement over the actual risk involved, and it has been suggested that the increased cardiac risk may only occur at high doses (Liperoti et al., 2005). Other authors have pointed out that the patients experiencing stroke events in the original trial of Brodaty, Withall, Altendorf, and Sachdev (2007) had other risk factors for stroke besides the use of risperidone in dementia (Lee et al., 2004). A recent meta-analysis (Katz et al., 2007) concluded that although cerebrovascular events and mortality observations across trials were more frequent in risperidone-treated groups, the frequency did not differ significantly from placebo groups.
Decreased cholinergic activity, primarily resulting from decreased acetylcholine concentrations caused by dementia-related neurological changes, has been associated with decreased cognitive ability in dementia, as well as increases in BPSD, including depression (Garcia-Alloza et al., 2005). Cholinesterase inhibitors, including tacrine, donepezil, rivastigmine, and galantamine, have been used to target these problems by increasing levels of acetylcholine, with some success, particularly in patients with mild to moderate dementia (Birks, 2006). A recent review of the literature on the effects of rivastigmine on BPSD reports that positive effects have been found for patients with a wide range of dementia, and that apathy and anxiety are among the behavioral domains demonstrating the most consistent positive response (Figiel & Sadowsky, 2008) (Level E).
Anticonvulsants
Though inconclusive, some evidence exists that anticonvulsants, through their modulation of GABA, may be another class of agents for treating BPSD and depressive symptoms. GABA concentrations are often decreased in cortical regions of the brain of patients with dementia, and medications that increase GABA levels have been shown to improve mood disorders (Sink et al., 2005). Trials of the anticonvulsant carbamazepine to treat BPSD have yielded contradictory results (Franco & Messinger-Rapport , 2006) (Level B), or have not reported data on depression. At least one clinical trial of valproate resulted in significant improvement in melancholic and sorrowful behaviors (Sival, Haffmans, Jansen, Duursma, & Eikelenboom, 2002), but the results of other small trials are contradictory (Sink et al., 2005) (Level B). Preliminary studies of another anticonvulsant, lamotrigine, in elderly patients with dementia noted improvement in symptoms of agitation and depression (Sajatovic, Ramsay, Nanry, & Thompson, 2007) (Level B).
Memantine, a drug that reduces excessive glutamate receptor signaling, has also been studied in patients with dementia. Glutamate signaling is important for learning and memory, but in some patients with dementia it may increase to “oversignalling” levels that destroy neurons. A recent review and meta-analysis of the research on memantine for the treatment of psychological symptoms (e.g., depression) of dementia showed small but significant improvements with limited adverse effects (Maidment et al., 2008).
The growth of complementary/alternative medicine may yield some helpful treatments for BPSD in the future. In particular, studies provide some support for the theory that Ginkgo biloba special extract EGb 761 enhances cognitive functioning and stabilizes mood in cognitively impaired elderly subjects (Woelk, Arnoldt, Kieser, & Hoerr, 2007). A review of the research (Birks & Grimely-Evans, 2007) concluded that the evidence that the extract has predictable and clinically significant benefit for older people with dementia or cognitive impairment is inconsistent and unconvincing. However, a recent trial of this extract involving patients with dementia found that compared to controls, those taking the extract experienced improvements in apathy and depression (Scripnikov, Khomenko, & Napryeyenko, 2007).
In summary, a wide variety of pharmacological treatments have efficacy (of varying degrees) in the treatment of depression in older adults with dementia, but care must be exercised in their use with generally frail older persons to avoid adverse effects. Alexopoulous, Jeste, Chung, Carpenter, Ross, and Docherty (2005) constructed an expert consensus response after surveying 50 experts in dementia from North America on preferred, alternate, and unacceptable pharmacological treatment choices for BPSD. The general consensus was that SSRIs were preferred for treating depression in patients with dementia. Further research appears to be needed to establish the effects of both older and newer pharmacological options for depression in dementia patients.
Non-Pharmacological Treatments for Depression in Dementia
Clinical guidelines specify the use of non-pharmacological treatments for BPSD before pharmacological treatments are tried (Buhr & White, 2006; Woods, 2004) (Level C). As well as avoiding potential effects of polypharmacy, drug interactions, or exacerbation of comorbid conditions, non-pharmacological treatments may improve the quality of life for the patient with dementia above and beyond the reduction of depression (Cohen-Mansfield, 2005). Yet, the current state of the evidence on non-pharmacological treatments is weak because few randomized controlled studies have been conducted, and therefore, it is difficult to provide information on the therapeutic benefits that these interventions may hold for older adults with dementia in long-term care.
Non-pharmacological therapies that specifically include depression as a target outcome fall roughly into three categories: (a) emotion-oriented therapies including reality orientation, validation therapy, and reminiscence therapy; and (b) brief psychotherapies including cognitive and behavioral therapy.
Emotion-Oriented Therapies
Reality Orientation Groups. Commonly conducted in long-term care settings, the original aim of Reality Orientation, as first developed for older people with mild to moderate dementia, was to reduce confusion by giving repeated orientation clues, e.g., the time of day, date, and season, but this was only partially successful. Researchers suggested that the main benefits were the stimulation from the social group and the positive impact on staff, who acquired a better knowledge of the residents and their earlier lives and interests, through which they were able to provide more person-oriented care (Moos & Bjorn, 2006). Livingston and colleagues (2005) reported the results of 11 studies consisting of randomized and quasi-experimental designs on reality orientation. The largest controlled trial (N=57 subjects) demonstrated no differences between reality orientation and an active ward orientation (Hanley, McGuire, & Boyd, 1981). The smaller sample nonrandomized studies mostly showed benefits of reality orientation in decreasing depressive symptoms or delaying institutionalization. The current research does not offer clear evidence of its benefits for older adults with dementia.
Reminiscence Therapy. Reminiscence therapy encourages persons with dementia to talk about their pasts, and may utilize audiovisual aids such as old family photos and objects to retrieve positive events and emotions. Reminiscence provides dementia sufferers a chance to interact positively with others; can enhance an individual’s sense of identity, sense of worth, or general well-being; and may also stimulate memory processes (Moos & Bjorn, 2006). Two reviews that included information on reminiscence therapy report potentially positive effects on depressed mood in patients with dementia, but caution that most trials were small or otherwise methodologically questionable and therefore the evidence is weak and inconclusive (Douglas, James & Ballard, 2004; Livingston et al., 2005).
Validation therapy. Validation therapy is a type of psychosocial intervention for elderly persons with dementia. Basically, a therapist accepts the disorientation of a person with dementia and validates his/her her feelings (Feil, 2002). This self-affirming intervention is based on the assumption that individuals return to unfinished conflicts in their past, providing a background for meaningful conversations addressing their feelings. Neal and Briggs (2003) reviewed trials of this therapy and reported that only one study (Toseland et al., 1997) showed a trend towards improvement of depression a year after completing validation therapy, but the finding was not statistically significant. Another recent study using validation therapy in a group format found similar results (Deponte & Missan, 2007). The empirical evidence for the usefulness of this therapy for depression in dementia is weak and unconvincing.
Brief Psychotherapies
Cognitive and Behavioral Therapy. Behavioral therapy requires a period of detailed assessment in which the personal triggers, behaviors, and reinforcers (also known as the ABCs: antecedents, behaviors, and consequences) are identified and their relationships made clear to the patient. The therapist will often use some kind of chart or diary to gather information about the manifestations of a behavior and the sequence of actions leading up to it. Interventions are then based on an analysis of these findings. The efficacy of behavioral therapy has been demonstrated in the context of dementia in a few earlier studies (Burgio & Fisher, 2000) (Level B). For example, there is evidence of successful reductions in wandering, incontinence, and other forms of stereotypical behaviors (Woods & Bird, 1999). Meares and Draper (1999) (Level F) presented case studies confirming the efficacy of behavioral therapy, but they noted that the behaviors had diverse causes and maintaining factors, and cautioned that behavioral interventions must be tailored to individual cases.
A recent systematic review examined 20 studies using behavioral management techniques for outcomes of depressive (3 studies) and neuropsychiatric symptoms (17 studies) in older adults with dementia (Livingston et al., 2005). Of the 3 on depression outcomes, one large randomized controlled trial showed significant improvement in depressive symptoms immediately post-treatment and at 6-month follow-up examination in two treatment conditions: (1) one emphasizing patient pleasant events and one emphasizing caregiver problem solving, as compared to treatment as usual and waitlist control conditions (Teri, Logdson, Uomoto, & McCurry., 1997) (Level A). The two smaller randomized trials also demonstrated significant reductions in behavioral symptoms compared to usual primary care (Benedict et al., 2000; Suhr, Anderson, & Tranel, 1999). However, no significant effects were found on depression (Benedict et al., 2000). The results of the larger randomized trial studies were consistent and showed benefits as compared to the control condition, and these beneficial effects were maintained over time.
Hyer and colleagues (1990) compared the effectiveness of a12-week group psychotherapy, in a cognitive behavioral format, to usual care in a small sample of 22 residents. At post-treatment, depression scores decreased in the treatment group but not in the control group. Koder (1998) discussed two case reports in which cognitive behavioral therapy was offered using techniques such as relaxation, distraction, and cognitive restructuring. Over the past decade, there has been an increasing interest in applying some of the brief therapeutic frameworks such as cognitive behavioral therapy (CBT) to dementia. For example, Teri, Curtis, Gallagher-Thompson, and Gallagher-Thompson (1994) reported positive findings from a clinical trial of CBT with people in the early stages of AD. Individual and group CBT has also been used by other researchers with some favorable results (Kipling, Bailey, & Charlesworth, 1999).
Both cognitive and behavioral therapies have obvious limitations, particularly for persons with severe dementia. Nevertheless, owing to the fact that these therapies have relatively simple conceptual models underpinning them, they have been shown to be helpful, even for severe cognitive impairment (Logsdon, McCurry, & Teri, 2007; Yuhas, McGowan, Fontaine, Czech, & Gambrell-Jones, 2006). For example, Douglas, James, and Ballard (2004) believes that a CBT perspective is very suitable for people with dementia, since many of the behavioral difficulties encountered emerge through one or more of the following cognitive features: cognitive misinterpretations, biases, distortions, erroneous problem-solving strategies, and communication difficulties. Hence, CBT offers a framework within which to understand the individual’s distressing experiences, and this understanding allows the clinician to target interventions more appropriately.
Overall, the evidence on non-pharmacological interventions as effective treatments for depression in older adults with dementia residing in long-term care is sparse and deficient. There are several limitations to the literature. First, most research studies have focused on behavioral and not depressive symptom outcomes. Second, the diversity of sample elderly populations makes it difficult to compare results across studies. Third, the majority of studies lack a description of intervention protocols or manuals making it difficult to understand, analyze, or replicate the treatment components. Finally, the inconsistency of follow-up protocols across studies provides further barriers to determine long-term effects of the interventions. A few psychosocial interventions such as group and individual behavioral therapies show some potential but require further investigation, improved study design, and clear intervention protocols for duplication and treatment component analysis.
Summary Take Home Points
- Depression is a common problem in older adults with dementia in long-term care settings.
- Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms of dementia, affect up to 95% of those with dementia.
- Reported prevalence of depression in elderly with dementia ranges from 30% to 96%.
- The depression screening protocol consists of the Mini Mental State Exam (MMSE) and either the Cornell Scale for Depression in Dementia (CSDD) or the Short Geriatric Depression Scale (SGSD) depending on MMSE score.
- The GDS should be used for patient scores of 15 to 23 on the MMSE.
- The CSDD should be used if the patient scores below 15 on the MMSE.
- If GDS is 6 or greater or CSDD is 11 or greater the primary health care provider should be notified for further evaluation and/or treatment for clinically significant depression.
- Apathy has been found to be related to a higher frequency of both minor and major depression.
- Depression may be a risk factor for progression from MCI to dementia.
- Expert consensus recommends SSRIs as the preferred pharmacological treatment for depression in patients with dementia.
- Due to physical and cognitive frailty, drug interactions, and polypharmacy may trigger depressive and other symptoms in some patients with dementia and patients may be susceptible to adverse effects.
- Clinical guidelines specify the use of non-pharmacological treatments for BPSD before pharmacological treatments.
- Scientific evidence for emotion-oriented therapies (Reality Orientation, Validation Therapy, and Reminiscence Therapy) is weak.
- Scientific evidence for cognitive and behavioral therapies is somewhat stronger. Results of a few large randomized trial studies were consistent and showed benefits as compared to control groups, and outcome effects on depression reductions were maintained over time.
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Katz, I., de Deyn, P. P., Mintzer, J., Greenspan, A., Zhu, Y., & Brodaty, H. (2007). The efficacy and safety of risperidone in the treatment of psychosis of Alzheimer's disease and mixed dementia: a meta-analysis of 4 placebo-controlled clinical trials. International Journal of Geriatric Psychiatry, 22(5), 475-484.
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Sajatovic, M., Ramsay, E., Nanry, K., & Thompson, T. (2007). Lamotrigine therapy in elderly patients with epilepsy, bipolar disorder or dementia. International Journal of Geriatric Psychiatry, 22(10), 945-950.
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Document Date: September 9, 2009
- Gellis, Z. D. (2006). Mental health and emotional disorders among older adults. In B. Berkman (Ed.), Oxford Handbook of Social Work in Health and Aging (pp. 129-139). New York: Oxford University Press.
This chapter provides a literature review on the state of the knowledge on geriatric mental health disorders among community- dwelling older adults.
- Hyer, L., Carpenter, B., Bishmann, D., & Wu, H. S. (2005). Depression in long-term care. Clinical Psychology: Science and Practice, 12(3), 280-299.
This article provides an overview of depressive disorders among older adults in long-term care settings.
This NIA report provides up-to-date knowledge on Alzheimer’s Disease.
Document Date: September 9, 2009
On-line Assessment Instruments
John A. Hartford Institute for Geriatric Nursing Try This. Try This: Best Practices in Nursing Care to Older Adults is a series of assessment tools to provide knowledge of best practices in the care of older adults. Includes a general assessment tool (SPICES), the Katz Index of Independence in Activities of Daily Living; Mental Status Assessment of Older Adults (Mini-Cog), and the Geriatric Depression Scale (GDS) in English or Spanish.
http://www.hartfordign.org/practice/try_this/
Neurotransmitter.net Psychiatric Rating Scales Index. This link takes you to a list of conditions. Selecting one of these conditions takes you to a list of assessment instruments, many of which can be downloaded and used in your practice, others take you to a link to contact the instrument developer about use. (Includes scales for Anxiety, Depression, Parkinson’s Disease, Alzheimer’s Disease and Dementia, and Schizophrenia, among others.)
http://www.neurotransmitter.net/ratingscales.html
On-line Fact Sheets
NIMH (National Institute on Mental Health) Depression and Suicide Facts. This link provides information about depression and suicide in older adults. It is written for the consumer and includes a self-screen.
http://www.nimh.nih.gov/health/publications/older-adults-listing.shtml
DVD and Video Resources
Assessment of Suicide Risk in an Older Adult Male. Geron 620 Mental Health and Aging, K-State Division of Continuing Education. Laurel Dinkel demonstrates an assessment of suicide risk in a white, older adult male. The video provides an outline of the interview including suicide risk and protective factors, the interview, and a post-interview discussion between Laurel and Janice Dinkel. This 60-minute DVD was developed specifically for social work students and is quite user-friendly for both bachelor’s and master’s level students. DVD, 60 minutes.
Initial Screening: Older Woman with Suspected Cognitive Impairment. Geron 620 Mental Health and Aging, K-State Division of Continuing Education. Laurel Dinkel demonstrates an initial assessment of a 77 y.o. woman with suspected cognitive impairment. The demonstration includes a brief history taking; assessment of current symptoms; administration of the Mini-Mental Status Exam, Clock Drawing Test, and Trail Making Test A and B; and presentation of recommendations and plan to the client and her daughter. The demonstration is followed by a post-interview discussion, between Laurel and Janice Dinkel, of the interview and the scoring and implications of the screening tools. This 60-minute DVD was developed specifically for social work students and is quite user-friendly for both bachelor’s and master’s level students. DVD, 60 minutes.
Janice Dinkel, MSW, LSCSW
Associate Professor of Social Work
Kansas State University
204 Waters Hall
Manhattan, KS 66506
(785) 532-4980
Document Date: September 9, 2009
The following case study was modified from the Assessment of Dementia case study downloaded at: www.gero-edcenter.org.
Mrs. J. is a 78-year-old, African American woman who lives in a small southern city. About a year ago, her husband died suddenly of a stroke, leaving Mrs. J. to live alone in her home of 52 years. It was the home where she had raised her three children, all of whom graduated from college, have professional careers, and now live in other parts of the state. Her family is a source of pride, and her home has numerous pictures of her children and grandchildren.
About 3 months ago, Mrs. J.’s oldest daughter, Vanessa, got a call from one of the neighbors. Vanessa lives a 4-hour drive from her mother—a drive that can often be longer in bad weather. The neighbor stated that Mrs. J. had walked to the neighborhood store in her pajamas and slippers. Because Mrs. J. has lived in the community for several years, people have been watching out for her since her husband died, and someone gave her a ride back home. Mrs. J. doesn’t drive, and the temperature was fairly chilly that day.
As a result of the call, Vanessa went to Mrs. J.’s home for a visit. Although she and her siblings had been calling Mrs. J. regularly, no one had been to the family home in about 6 months. Vanessa was shocked at what she saw!
Mrs. J. had been a cook in a school cafeteria earlier in life and always kept her own kitchen spotless. But now the house was in disarray with several dirty pots and pans scattered throughout different rooms. In addition, odd things were in the refrigerator such as a light bulb and several pieces of mail. Many of the food products were out of date, and there was a foul smell in the kitchen. Trash covered the counters and floor.
Vanessa contacted her siblings to ask them if their mother had told any of them that she wasn’t feeling well. Her brother, Anthony, remarked that their mother would often talk about Mr. J. in the present tense—but he thought that it was just her grief about his death. The younger brother, Darius, reported that his wife was typically the one who called their mother—about once a month. He didn’t know if there had been any problems—his wife never said anything about it to him.
Vanessa also contacted the pastor of her church, Rev. M. He stated that Mrs. J. had been walking to church on Sundays, as usual, but he did notice that she left early a few times and other times seemed to come to service late. But like the brother, Anthony, he thought that this behavior was probably a grief reaction to the loss of her husband.
A final shock to Vanessa was when she went through her mother’s mail. There were several overdue bills and one urgent notice that the electricity was going to be cut off if the balance wasn’t paid. She owed several hundred dollars in past due heating, electric, and telephone bills.
Vanessa contacted her mother’s primary care physician (Dr. P.) who said that she had last seen Mrs. J. for her regular checkup 3 months earlier and that she had missed her last appointment a week ago. Dr. P. said that her staff had called to make another appointment but that her mother hadn’t called them back yet. The doctor said that she had written a reminder for the nurse to contact Vanessa the same day that Vanessa called. Mrs. J. is being treated with medication for arthritis, hypertension, and gastroesophogeal reflux (GERD), and all of these were under control at the last visit. Her weight was stable, and her only complaint was some difficulty staying asleep at night. Dr. P. reported that her mother’s mood was sad but had improved some in the month before the last visit. The doctor asked about memory and concentration, but her mother denied having any problems and did not seem to be confused at the time of the last visit. When the doctor heard about the recent problem at the store and Vanessa’s description of her mother’s house, she was very surprised and asked that Mrs. J. be brought in immediately.
Activity #1. Class Discussion
Ask students to assume that they are social workers working with the primary care physician and that they have been asked to see Mrs. J. and her daughter prior to their meeting with Dr. P.
Ask students to consider the following assessment questions:
- What psychosocial factors are present in the case example that impact Mrs. J.’s physical and mental well-being?
- What instruments could be used to evaluate the cognitive and mental functioning of Mrs. J.?
- What instruments could be used to evaluate symptoms of depression?
- What should be the role of Mrs. J.’s family in care planning? Are there other informal support systems that should be involved?
- What multicultural issues are present in this case study?
- What issues are relevant to establishing rapport with Mrs. J. and her family?
- What type(s) of interventions would be appropriate?
- How would the interventions be evaluated?
- What programs or resources might be appropriate for Mrs. J.?
- What would characterize a culturally competent intervention?
- What would characterize culturally competent services and programs?
- What are some gaps in service that Mrs. J. might face?
Activity #2. Role plays
- Divide students into groups of three.
- Ask students to go online and download the MMSE.
- Ask the students to assume the following roles:
- Mrs. J.
- Vanessa
- Social worker
If a particular task only requires two people, the third person becomes an observer and after the task provides the feedback (questions and discussion) to each participant on the following points:
- What did you do that you liked?
- What would you do differently next time?
- This is what you did that I liked…
- This is what you might consider doing differently next time…
- If time allows—and if appropriate for the particular students, you may ask the client in the role play to provide feedback to the social worker.
- This is what you did that I liked…
- This is how I felt when you...
- This is what you might try next time…)
Remind students that the case example only provides an outline, they are to improvise additional details as needed. (Be kind to one another. The goal is not to “stump the chump” but to have an opportunity to practice using skills with an older adult and family member.)
Depending on the level and experience of the students, it may be necessary to model the tasks before doing the role plays.
Task #1: Social worker role plays administering an MMSE examination to Mrs. J. (Third student observes.) Score the MMSE. Based on the details of the case study, determine what stage Mrs. J. is on the Global Deterioration Scale. After the role play, the observer provides feedback.
Task #2: Rotate roles. Based on the MMSE score, select either the CSDD or the Short GDS. Social worker introduces the screening and conducts a depression screening with Mrs. J.
- Obtain the person’s agreement to be screened.
- Explain the purpose for the screening.
- Administer and score the depression screening instrument as instructions direct.
- [If necessary based on the MMSE score, rotate roles and the social worker conducts the CSDD interview with Vanessa.]
Task #3: Rotate roles. Social worker discusses his/her concerns and makes initial treatment referrals for further diagnostic assessment to Dr. P. for possible psychotherapy and antidepressant medication.
Discuss the results of the MMSE, the GDS, and the depression screen with Mrs. J. and Vanessa.
Task #4 (optional): Ask one student to take the role of the social worker and the other to take the role of Dr. P. Social worker presents his/her concerns and the results of the MMSE, the Global Deterioration Scale, and the depression screen to Dr. P. (Remind students that Dr. P’s time is quite limited and that they will need to be concise and focused in their presentation of Mrs. J and her situation.)
Document Date: September 9, 2009
Download this PowerPoint for Chapter 5 of the Mental Health Resource Review.
Document Date: September 9, 2009
Zvi D. Gellis, PhD. University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
Future Research
In each of the evidence-based literature reviews on geriatric mental health care, we have presented the current knowledge on effectiveness for known geriatric mental health interventions for anxiety, depression, schizophrenia, and depression in dementia. Further research is needed in the topical areas that were examined, and these needs are discussed below.
Late Life Anxiety. Further research on late life anxiety is needed in all areas since the knowledge base is in its infancy. Knowledge gaps exist on the frequency and severity of subthreshold anxiety in community dwelling older adults. Further studies are needed on the prevalence of anxiety in various settings such as primary care, home health care, ophthalmology clinics, assisted living facilities, and in the community including naturally occurring retirement communities (NORCs). Especially important is research on differential diagnosis of anxiety and depression and medical illnesses. Too little is known about the effectiveness of psychosocial treatments aside from cognitive behavioral therapy (CBT) and its effectiveness with various older populations, such as those with mild cognitive impairment (MCI) or visual impairments. Research on minorities is also important, an area in which too little is known.
Late Life Depression. Psychosocial interventions for late life depression have been demonstrated to be effective among older adults, particularly those who reject medication due to unpleasant side effects or who are coping with low social support or stressful situations. Evidence-based (Level A) manualized approaches, including CBT-Level A), interpersonal (IPT-Level A), and problem-solving (PST-Level A) therapies, are effective intervention alternatives or adjuncts to medication treatment.
Further research is needed on prevalence of mental health problems in community-dwelling older adults living in naturally NORCs and assisted living facilities. Providing social workers with training to screen, assess, and treat individuals in their homes for mental health problems, such as depression and/or anxiety comorbid with medical illnesses, will likely increase individual community tenure, decrease the likelihood of a premature hospitalization or institutionalization, and increase quality of life.
Research reveals that when older adults are screened and identified with depression, if given a choice, they prefer talk therapy to medication for treatment of their mental health problems. Therefore, further studies need to focus on brief interventions that are feasible, cost-effective, and replicable in various settings including home-based interventions in home health care, NORCs, and assisted-living settings. Community-based depression interventions are relatively new, and to date, only one research group has published positive findings in home health care using a psychosocial intervention. A majority of the research has been completed in primary care settings. In addition, culturally sensitive depression intervention research is needed with older minority populations. New and exciting research on tele-healthcare interventions for older adults with depression and heart disease is trail-blazing new frontiers with potentially robust outcomes.
Schizophrenia. As in other disorders, additional research is needed on the treatment, particularly psychosocial treatment, of older adults with schizophrenia. These studies should include adults 60 and over with early, late, and very late onset forms of the illness; minority subjects (ethnic minority, immigrant, refugee, and GLBT); and individuals living in a range of settings (community, assisted living, supported housing, and nursing homes). Many of the current treatment studies are limited by problems such as small sample sizes, including both middle-aged and older adults, and including only white subjects. In particular there is a need to investigate the degree to which the six interventions identified by the Robert Woods Johnson Foundation (assertive community treatment, supported employment, family psychoeducation, illness management and recovery, integrated dual disorders treatment for individuals with co-occurring severe mental illness and substance use problems, and medication management, [Drake, Merrens, & Lynde, 2005]) are effective in working with older adults and whether/how they might need to be adapted. For example, should supported employment be expanded for individual placement and support, and could family psychoeducation be used in its present form for caregivers who are not family members? In particular, given the trend toward maintaining people longer in the community, much more work needs to be done examining the effectiveness of community-based interventions. In addition to further study of these six interventions, additional study is needed on interventions like skills training, PST, and CBT that have been demonstrated effective with older adults with other disorders or with younger individuals with schizophrenia. Finally, additional study is needed clarifying the risks and benefits of the various pharmacological interventions for schizophrenia. For example, a great deal needs to be learned about the risk of serious side effects like transient ischemic attacks (TIAs), elongation of heart rate (QT) interval, and metabolic syndrome in older adults, particularly given the widespread use of atypical antipsychotic drugs in both individuals with behavioral and psychological symptoms of dementia, as well as those with psychotic disorders.
Other key areas in which additional research is needed include the course of the illness of early onset of schizophrenia (EOS), and the nature of late onset of schizophrenia (LOS) and very late onset of schizophrenia (VLOS). The classic longitudinal studies of the outcome of schizophrenia were conducted with participant groups that had little exposure to antipsychotic medication during the early years of their illness and no exposure to atypical antipsychotic drugs. Additionally, the early longitudinal studies employed global measures of symptoms. New research should include individuals living in a variety of settings. This is particularly important since it is unclear whether some of the differences in functioning seen between older adults living in the community, assisted living, and nursing homes is a cause or an effect of residence status. A more fine-grain longitudinal assessment is very important to understanding how positive, negative, cognitive, and mood symptoms change over time, and how functioning is affected by these changes. Studying LOS and VLOS has been hampered by the fact that these conditions occur at a very low rate. The field would benefit from multi-site collaborative research on these conditions.
Late Life Dementia and Depression. The reviews identified gaps in our knowledge regarding the effectiveness of interventions that are promising but untested or are in widespread use for reasons of tradition. Nonpharmacological interventions for individuals with depression and dementia fall into this category. Evidence on efficacy of treatment of depression in long-term care is sparse and deficient. Reminiscence therapy has been studied widely with mixed results. The life review model is a more structured approach and may be more effective. Indeed, a few psychosocial interventions such as group and individual behavioral therapies show some potential but require further investigation, improved study design, and clear intervention protocols for duplication and treatment component analysis. For these interventions, research gaps consist of questions regarding effectiveness, efficacy, and applicability to other populations and settings. The knowledge base will be bolstered with the use of robust research designs, including randomized trial and longitudinal design methodologies.
Geriatric Mental Health Policy and Future Research
A social work focus on several policy priorities can support the provision of evidence-based mental health services to older adults. First, a delivery model of integration of health, mental health, and aging services for older adults should be considered. This has the potential to improve mental health screening in medical and community-based nonmedical settings. Such a model may require ongoing training, consultation, and information to providers, caregivers, and individuals. Second, re-examining Medicare should be a policy priority for service optimization. The financing mechanisms and fiscal viability of geriatric services should be considered so that evidence-based service delivery can be replicated, supported, and sustained. Potential improvements include optimizing reimbursements for providers and identification of the full array of mental health services that can be offered under Medicare. Third, service agencies can make more efficient use of mental health and health professionals by developing a workforce efficiency mechanism of alternative service roles for paraprofessionals and volunteers who can be recruited from ethnic minority populations to provide culturally competent services. Finally, increasing research knowledge on effective intervention models for diverse older populations is an essential priority to support the delivery of best practices.
References
Drake, R. E., Merrens, M. R., & Lynde, D. W. (Eds.). (2005). Evidence-based mental health practice: A textbook, New York: W. W. Norton & Company, Inc.
Document Date: September 9, 2009
Zvi D. Gellis, PhD. University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago.
Mental Health and Older Adults
Teaching Modules
- John A. Hartford Institute for Geriatric Nursing fundamental geriatric curriculum resources, Try This. This site provides free fully scripted PowerPoint teaching slides that comprise state-of-the art information in best practices nursing care for older adults. The material is practical and user-friendly. Each chapter is organized with Competencies, Content Outline, Instruments and Scales, Case Study, Experiential/Clinical Activities, and Post-test.
- NursingCenter.com also has videos on a number of topics relevant to social work, such as administration of the Geriatric Depression Scale, Mini-Cog, the Recognition of Dementia Scale and the Katz Index of Independence. The videos include a demonstration of the instrument, a discussion of the problem, debriefing, and the implications of the assessment for intervention/treatment planning after the assessment. The assessments are conducted in a hospital setting, so instructors may need to discuss with their students the influence of context on the process of evaluation. Overall, the quality of the videos is good as are the other Try This resources. While these resources were developed for nursing students, they are readily applicable for social work students. [To show these full screen, you will need to click the full screen icon in the lower right corner.]
- Mental Health and Aging curriculum modules for MSW programs. (California State University, Los Angeles, School of Social Work) Three modules on mental health (HBSE), research methods, and mezzo and macro practice. The HBSE section contains a useful table comparing characteristics of delirium, dementia, depression, anxiety, and psychosis. There also is a section addressing cultural factors in aging that may be useful for the advanced practice curriculum. The research section includes Contains lecture outlines, figures and tables, case vignettes.
Web Resources
General resources on aging
- National Institutes of Health National Institute on Aging. This site provides information on health issues and ongoing research in aging. Includes a link to a Spanish language website.
- CSWE Gero-Ed Center. The CSWE Gero-Ed Center aims to prepare social work faculty to respond to the demographic realities of our aging society. This Web site is the online resource for gerontologically-competent social work faculty, students, and practitioners. Provides links to eLearning course, conferences and educational opportunities, Aging Times, and a quick navigation resource that facilitates access to other resources for practitioners, students, and faculty.
- Agency for Healthcare Quality and Research (AHRQ). The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision making. This site allows one to search for specific topics. It also provides links to treatment guidelines, systematic reviews, research reports, and a number of other resources.
- American Society on Aging (ASA). ASA is the largest organization of multidisciplinary professionals in the field of aging. They offer resources, publications, and educational opportunities geared to enhance the knowledge and skills of people working with older adults and their families.
- American Psychological Association topic: Aging. This site news articles and press releases, (older) journal articles, books and videos from APA Press, and links to other sites.
- NASW Aging area of practice. Links to news and journal articles related to aging.
- HELPGUIDE. Helpguide is a non-profit resource that provides consumer links to information and referrals for a mental health, healthy lifestyles, and aging.
- National Institute on Mental Health (NIMH) Pages about Older Adults. This site provides links to other NIMH sites addressing mental health and older adults.
Assessment instruments
- John A. Hartford Institute for Geriatric Nursing Try This. Try This: Best Practices in Nursing Care to Older Adults is a series of assessment tools to provide knowledge of best practices in the care of older adults. Includes a general assessment tool (SPICES), the Katz Index of Independence in Activities of Daily Living; Mental Status Assessment of Older Adults (Mini-Cog), and the Geriatric Depression Scale (GDS) in English or Spanish. The Try This resources were developed for a nursing curriculum, but they are quite appropriate for social work students and practitioners.
- Neurotransmitter.net Psychiatric Rating Scales Index. This link takes you to a list of conditions. Selecting one of these conditions takes you to a list of assessment instruments, many of which can be downloaded and used in your practice, others take you to a link to contact the instrument developer about use. (Includes scales for anxiety, depression, Parkinson’s Disease, Alzheimer’s Disease and dementia, schizophrenia, among others.)
- Yesavage Geriatric Depression Scale. This site provides a link to the short (15-item) version of the scale and allows clinician administration, scoring, and downloading for your records. There also is a bibliography on the instrument and a streaming video with information on assessing suicidality.
- Mini-International Neuropsychiatric Interview (MINI). Register and download paper and pencil version for free. The MINI is available in several languages.
Information
- Anxiety Disorders Association of America Anxiety in the Elderly. The ADAA is an association of consumers, family members, researchers, and therapists working with individuals with anxiety disorders. This links to a brief clearly written discussion of anxiety and its treatment written for consumers and family members. This site includes links to more detailed discussions of the different anxiety disorders, of psychosocial and medication therapy, of how to choose a therapist, and to self-help groups. Finally, the ADAA site provides links to self-tests for each of the anxiety disorders.
- Older adults and mental health—Chapter 5, Mental Health: A Report of the Surgeon General (DHHS, 1999). This link takes you to an online version of this 72 page chapter. Scroll down to and open the PDF entitled, "Mental Health: A Report of the Surgeon General" (pages 326-350) (1999)” – paying special attention to the page numbers. Chapter 5 begins on the 5th page of the PDF and continues in the next PDF (pages 351-375) back on the main page. Even though the chapter is dated, there is a lot of good information. The main section that needs updating is the section on pharmacotherapy.
- Medline Plus Anxiety. Medline Plus is a service of the National Library of Medicine and the National Institutes of Health. This site lists a number of resources on anxiety and anxiety disorders including articles, directories, glossaries, links to associations, and both disorder-specific and population-specific information. This site is geared to professionals, including social workers.
- Medline Plus Schizophrenia. Medline Plus is a service of the National Library of Medicine and the National Institutes of Health. This site lists a number of resources on schizophrenia including articles, directories, glossaries, links to associations, and both disorder-specific and population-specific information. This site is geared to professionals, including social workers.
- National Alliance on Mental Illness (NAMI). NAMI is nation’s largest grassroots organization for people with mental illness and their families. Founded in 1979, NAMI has affiliates in every state and in more than 1,100 local communities across the country. NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life for persons of all ages who are affected by mental illnesses. These sites provide information on psychoses, depression, suicide, panic disorder, and obsessive compulsive disorder; medications; and links to other resources including discussion groups, treatment recommendations, and support. The NAMI site is one of the most useful sites for general information on mental illnesses, though its focus is more general than just older adults.
- NIMH Depression and Suicide Facts. This link provides information about depression and suicide in older adults. It is written for the consumer and includes a self-screen.
- American Geriatric Society (AGS) Anxiety. The AGS discussion of anxiety is written for the consumer or family member. The AGS discussion is a bit more detailed than that of the ADAA. Both the font size and color may make it difficult to read for older adults, though the information included is useful and quite appropriate for family members and social work students.
Aging-related databases and search engines
- AARP Ageline Database. AgeLine abstracts the literature of social gerontology as well as aging-related research from psychology, sociology, social work, economics, public policy, and the health sciences. It covers aging-related issues for professionals in aging services, health, business, law, and mental health. AgeLine also includes selected consumer content. AgeLine summarizes journal articles, books and chapters, research reports, dissertations, gray literature, and educational videos from many publishers and organizations, including AARP. Links to full text or ordering options are included wherever possible.
- National Registry of Evidence-based Programs and Practices (NREPP), a service of the Substance Abuse and Mental Health Services Administration (SAMHSA). NREPP is a searchable database of interventions for the prevention and treatment of mental and substance use disorders. The database can be search according to a number of criteria, including age group, ethnicity, and area of interest (e.g., older adults/aging, suicide prevention, alcoholism). SAMHSA has developed this resource to help people, agencies, and organizations implement programs and practices in their communities. Specific practices are described and include a bibliography, information on training, research, and implementation. This is a highly recommended resource for evidence-based practices in all areas including older adults. It should be checked regularly.
Films and Media
- Assessment of Suicide Risk in an Older Adult Male. Geron 620 Mental Health and Aging, K-State Division of Continuing Education. Laurel Dinkel demonstrates an assessment of suicide risk in a white, older adult male. The video provides an outline of the interview including suicide risk and protective factors, the interview, and a post-interview discussion between Laurel and Janice Dinkel. This 60 minute DVD was developed specifically for social work students and is quite user-friendly for both bachelor’s and master’s level students. DVD, 60 minutes. $50.00 The DVD was prepared by Janice Dinkel, Associate Professor of Social Work, Kansas State University and Laurel Dinkel, private clinical geriatric practice, Norman, OK. The DVD may be obtained by contacting: Janice Nikkel, Program Coordinator, Division of Continuing Education, 244 College Court Bldg., Kansas State University, Manhattan, KS 66506, Phone 785.532.2548, FAX 785.532.3779, jnikkel@k-state.edu, www.dce.k-state.edu
- Initial Screening: Older Woman with Suspected Cognitive Impairment. Geron 630 Mental Health and Aging, K-State Division of Continuing Education. Laurel Dinkel demonstrates an initial assessment of a 77 y.o. woman with suspected cognitive impairment. The demonstration includes a brief history taking; assessment of current symptoms; administration of the Mini-Mental Status Exam, Clock Drawing Test, and Trail Making Test A and B; and presentation of recommendations and plan to the client and her daughter. The demonstration is followed by a post-interview discussion, between Laurel and Janice Dinkel, of the interview and the scoring and implications of the screening tools. This 60 minute DVD was developed specifically for social work students and is quite user-friendly for both bachelor’s and master’s level students. DVD, 60 minutes. $50.00. The DVD was prepared by Janice Dinkel, Associate Professor of Social Work, Kansas State University and Laurel Dinkel, private clinical geriatric practice, Norman, OK. . The DVD may be obtained by contacting: Janice Nikkel, Program Coordinator, Division of Continuing Education, 244 College Court Bldg., Kansas State University, Manhattan, KS 66506, Phone 785.532.2548, FAX 785.532.3779, jnikkel@k-state.edu,www.dce.k-state.edu
- John A. Hartford Institute for Geriatric Nursing fundamental geriatric curriculum resources, Try This. This site has videos on a number of topics relevant to social work, such as administration of the Geriatric Depression Scale, Mini-Cog, the Recognition of Dementia Scale and the Katz Index of Independence. For detailed description, see listing above under Teaching Modules.
- Depression with Older Adults. Dr. Peter A. Lichtenberg demonstrates his multimodal approach to treating this common presenting problem in older clients. There are many possible contributing factors to depression in this population, as issues of grief, loss, and physical decline are unavoidable aspects of later life. In this session, Dr. Lichtenberg works with a 78-year-old woman whose husband is ill, but is controlling. Because many of her friends have died or live elsewhere, the client has no support network to help with the stressors she faces. Dr. Lichtenberg works with her to help to define her problems and focus on what she can change. The session is more geared toward information gathering than therapy per se. Preceding the interview, there is a question and answer session highlighting different aspects of his treatment approach. Following the interview, there is a detailed discussion illustrated with clips from the interview. The DVD focuses on the beginning of treatment, and the viewer would benefit from seeing a second DVD illustrating subsequent sessions and response to treatment. The viewer also would benefit from a discussion of the roles of ethnicity, socioeconomic status, and cultural or religious values as contributing factors to depression as well as how these issues are addressed in this approach. DVD, 100+ minutes, American Psychological Association. $99.95 (member/affiliate $69.95).
- Interpersonal Psychotherapy for Older Adults with Depression. Gregory A. Hinrichsen demonstrates his approach to working with older clients suffering with this common disorder. Interpersonal psychotherapy (IPT) is a time-limited therapy that has been found to be effective in the treatment of depression in different age groups, including older adults. IPT focuses on one or two interpersonally relevant problems including interpersonal role disputes, role transitions, grief, and interpersonal deficits. In this session, Dr. Hinrichsen works with a 77-year-old woman who recently lost her husband following a long period of caregiving during which one of her sons died. Despite the presence of many depressive symptoms, the client is unaware that she has a major depression. Dr. Hinrichsen demonstrates effectively the process of interpersonal psychotherapy as he helps the client to understand depression, its precipitants, and the path to improvement. DVD, 100+ minutes, American Psychological Association. $99.95 (member/affiliate $69.95).
Screening Tools for Identifying Depression Disorders in Older Adults
Dementia Assessment Instructions
Table Sources
Alexopoulos, G. S., Abrams, R., Young, R., & Shamoian, C. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23, 271-284.
Borson, S., Scanlan, J. M., Brush, M., Vitallano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15(11), 1021-1027.
Beck, A. T. & Beck, R. W. (1972). Screening depressed patients in family practice. A rapid technic. Postgraduate Medicine, 52(6), 81-85.
Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P., Adey, M. B., Rose, T. L. (1982). Screening tests for geriatric depression. Clinical Gerontologist 1: 37-44.
Folstein, M., Folstein, S., & McHugh, P. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-61.
Kroenke, K., & Spitzer. R. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 509-515.
Radloff, L. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385-401.
Document Date: September 9, 2009
We acknowledge the contributions of the following individuals to the Resource Reviews:
Bethany Mikovitz-Wibby - Case Western Reserve University
Elizabeth Noble – San Jose State University
We acknowledge the contributions of the following faculty for providing peer reviews and helpful suggestions on various chapters of the Resource Reviews:
Audrey Begun, University of Wisconsin, Milwaukee
Diana DiNitto, University of Texas, Austin
Lala Straussner, New York University
Michie Hesselbrock, University of Connecticut
Beth Reed, University of Michigan
Document Date: September 9, 2009
Suggested Citation for Resource Reviews:
AUTHOR NAMES for specific chapter (2008). CHAPTER TITLE. In S. Diwan (ed.), SOURCE (list the title of the particular Resource Review ). PUBLISHER. Retrieval Location (list overall URL for the particular Resource Review.)
Examples:
Farkas, K.J. & Drabble, L. (2008). Research questions and future research directions. In S. Diwan (Ed.), Substance Use and Older Adults Resource Review. Alexandria, VA: CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Retrieved from www.gero-edcenter.org/mac.
Gellis, Z.D., McClive-Reed, K., & McCracken, S.G. (2008). Depression in older adults with dementia. In S. Diwan (Ed.), Mental Health and Older Adults Resource Review. CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Retrieved from www.gero-edcenter.org/mac.
Christ, G. & Diwan, S. (2008). Role of social work in managing chronic illness care. In S. Diwan (Ed.), Health Care and Older Adults Resource Review. CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Retrieved from www.gero-edcenter.org/mac.
Document Date: September 9, 2009