Handbook of Mental Health and Aging

Nathan Hantke, Amit Etkin, Ruth O'Hara

• Publisher: Academic Press
• Year: 2020
• ISBN:
  9780128004937
• Edition: 3
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Handbook of Mental Health and Aging, Third Edition provides a foundational background for practitioners and researchers to understand mental health care in older adults as presented by leading experts in the field. Wherever possible, chapters integrate research into clinical practice. The book opens with conceptual factors, such as the epidemiology of mental health disorders in aging and cultural factors that impact mental health. The book transitions into neurobiological-based topics such as biomarkers, age-related structural changes in the brain, and current models of accelerated aging in mental health. Clinical topics include dementia, neuropsychology, psychotherapy, psychopharmacology, mood disorders, anxiety, schizophrenia, sleep disorders, and substance abuse. The book closes with current and future trends in geriatric mental health, including the brain functional connectome, repetitive transcranial magnetic stimulation (rTMS), technology-based interventions, and treatment innovations.

• Identifies factors influencing mental health in older adults
• Includes biological, sociological, and psychological factors
• Reviews epidemiology of different mental health disorders
• Supplies separate chapters on grief, schizophrenia, mood, anxiety, and sleep disorders
• Discusses biomarkers and genetics of mental health and aging
• Provides assessment and treatment approaches

Chapter 1

Concepts and issues in mental health and aging

Nathan Hantke^{1, 2} and Ruth O’Hara^{3, 4, 5}, ¹Department of Neurology, Oregon Health and Science University, Portland, OR, United States, ²Mental Health and Neuroscience Division, VA Portland Health Care System, Portland, OR, United States, ³Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States, ⁴Sierra Pacific Mental Illness Research, Education and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, United States, ⁵Stanford/VA Alzheimer’s Center, Palo Alto, CA, United States

Abstract

The second and last prior edition of this book was published in 1992, seemingly a lifetime ago within the field of geriatric mental health research, and perhaps truly a lifetime ago for some readers. Over the 28 year span leading to the current version, the field of mental health and aging has experienced an unprecedented level of change and growth. The fundamental taxonomy of many mental health disorders has been questioned, adjusted, and redefined. The detection of biomarkers has taken a center stage in health care, and the conceptualization of mental health research within multidimensional constructs is a radical departure from dichotomous-based classification models for psychiatric disorders. Neuroimaging techniques have grown at an unprecedented rate. For example, the first publications on the technique of blood oxygen level–dependent imaging, vital in functional MRI, were released while the last edition of this book was in press. The role of mental health in whole-body well-being has gained traction, particularly as it applies to aging. The complex interplay of psychiatric symptoms, cognition, daily functioning, and aging is increasingly appreciated in medical care. Increasing thoughtfulness toward the importance of cultural competence, recognition of the impact of ethnic discrimination on mental health, and the integration of person-centered language into the lexicon of patient care are all relatively new, yet sorely needed changes within mental health care. The goal of the present chapter is to briefly synthesize the current state of the field and discuss the critical issues facing researchers and clinicians providing care to older adults.

Keywords

Mental health; aging; neurobiology; cognition; psychotherapy

The second and last prior edition of this book was published in 1992, seemingly a lifetime ago within the field of geriatric mental health research, and perhaps truly a lifetime ago for some readers. Over the 28 year span leading to the current version, the field of mental health and aging has experienced an unprecedented level of change and growth. The fundamental taxonomy of many mental health disorders has been questioned, adjusted, and redefined. The detection of biomarkers has taken a center stage in health care, and the conceptualization of mental health research within multidimensional constructs (e.g., RDoC) is a radical departure from dichotomous-based classification models for psychiatric disorders (Cuthbert, 2015). Neuroimaging techniques have grown at an unprecedented rate. For example, the first publications on the technique of blood oxygen level–dependent imaging, vital in functional MRI, were released while the last edition of this book was in press (Kwong, 2012; Ogawa, Lee, Kay, & Tank, 1990). The role of mental health in whole-body well-being has gained traction, particularly as it applies to aging. The complex interplay of psychiatric symptoms, cognition, daily functioning, and aging is increasingly appreciated in medical care. Increasing thoughtfulness toward the importance of cultural competence, recognition of the impact of ethnic discrimination on mental health, and the integration of person-centered language into the lexicon of patient care are all relatively new, yet sorely needed changes within mental health care.

Yet, many fundamental aspects of mental health care in older adults remain little changed. Many chapters from the last edition are still directly important in today’s health care system. Clinical care and research in older adults are sorely underfunded despite generations of warning of the now pending “silver tsunami” of baby boomers reaching older age. Dementia disorders, while heavily studied, continue to have no cure and place heavy burden upon patients, families, and the health care system despite modest strides in research. However, there has been substantial progress made in even the areas noted above, and many of the trends in research predicted by Dr. Barry Lebowitz and Dr. George Niederehe in the prior edition of this Handbook have come to fruition (Lebowitz & Niederehe, 1992). They accurately predicted increased attention to the relationship between sleep disorders and aging, which is now recognized as an important area of study and necessitated two chapters on the topic in the current edition. Drs. Lebowitz and Niederehe similarly successfully predicted increased recognition of the role of social isolation on mental health in older adults, and the increasing acknowledgment of caregiver burden within our society (Bott, Sheckter, & Milstein, 2017).

The goal of this chapter is not to provide new theories or provide a comprehensive review of topics; we will leave that to the authors of the following chapters. Instead, we aim to briefly synthesize the current state of the field and discuss the critical issues facing researchers and clinicians providing care to older adults. Mental health care is presently in an exciting time, as collaborations between neurochemistry, cognitive neuroscience, psychology, and psychiatry have recently resulted in fascinating breakthroughs with the potential to improve clinical care. We believe the following chapters, written by leaders in these areas, capture this zeitgeist. Importantly, we would like to first acknowledge Drs. James Birren, Bruce Sloane, and Gene Cohen, the previous editors of this Handbook of Mental Health and Aging (1980; 1992), who have left us gigantic shoes to fill and a robust foundation upon which to develop this book.

Critical issues in mental health

The current edition of this book, similar to past editions, is broadly divided into overarching themes or sections: conceptual factors associated with mental health, behavioral neuroscience and aging, psychopathology in late-life, assessment in older adults, and intervention. The book begins with Drs. Renn, Areán, and Unützer discussing the epidemiology of select mental health disorders in late-life, including associated risk factors. As noted in their chapter, improvement in medical care has resulted in longer life expectancy and an associated need for more providers who specialize in providing mental health care for older adults. This increase in the geriatric population has significant implications for the health care system, a concern which has been espoused by multiple authors and work groups for the past decades (Institute of Medicine, 2012). Providers working with geriatric patients need related training to provide adequate care, as older adults often present with complicated medical problems that may exacerbate or mask mental health disorder. In addition, as discussed by the authors, the prevalence, risk factors, and presentation of mental health disorders may be very different in older adults as compared to younger adults.

In his chapter, Dr. Bott discusses the economic implications and history of U.S. health policy associated with geriatric mental health. There is growing evidence that preventative care leads to lower health care utilization, which in turn results in financial benefit. The creation of a health care infrastructure that is proactive to medical problems, as compared to reactive, is a complicated endeavor. Dr. Bott and colleagues discuss such a model for Alzheimer’s disease care, providing a comprehension plan of targeting outpatient treatment of chronic medical issues, managing acute cognitive concerns, and providing caregiver support (Bott et al., 2019). They propose that this plan would theoretically save billions of health care dollars while concurrently improving the quality of care, utilizing coordination of care and protective interventions (Bott et al., 2019). Such programs aimed at improving the efficiency of mental health care through prevention and integrated care are at the forefront of proposed high-value care delivery policies, and a potential critical component of improving care for the growing number of older adults. Similar collaborate care models have already been shown to be very effective in treating depression in older adults (Hunkeler et al., 2006).

Mental health disorder in older adults

Clinicians and researchers who work with older adults appreciate the complex nature of mental health care within this population. Complicated medical problems (including cognitive impairment) may interact with and exacerbate mental health symptoms in older adults. Dr. Moore and her colleagues discuss such interactions in the context of stressors. The authors provide an excellent overview on how stress results in cumulative “wear and tear” on the older adult body, including immune dysregulation, inflammatory response, increased risk for cognitive dysfunction, and multiple other negative outcomes. Similarly, Drs. Hein, Dols, and Eyler discuss how bipolar disorder in older adults differs from that seen in younger adults, and discuss the current state of research on accelerated aging and cognitive impairment in older adults with bipolar disorder. This relationship between cognitive impairment, aging, and mental health is a common theme throughout the book and discussed in multiple other chapters.

The understanding of anxiety, depression, and suicidality in older adults has lagged behind the extensive empirical work seen in younger adults. What is known suggests that the etiology and symptom presentation may differ between younger and older adults, requiring special consideration when conceptualizing and diagnosing these disorders. Drs. Beaudreau and colleagues discuss how anxiety symptoms may present in older adults, and propose appropriate assessment and psychotherapy approaches, including an up-to-date review of the effectiveness of cognitive behavioral therapy for anxiety disorders in older adults. Drs. Jordan and Anker review the current research in suicide in late-life, including risk factors, current psychological theories, and recommended treatments. Within their subsection on neurodegeneration, the authors discuss recent research correlating structural differences shown on neuroimaging and associated executive dysfunction in those with suicidal ideation and those whom attempt suicide. Specifically, that executive dysfunction increases the overall likelihood of suicide in older adults (Gujral et al., 2014). Such findings reflect the growing appreciation of the relationship between cognition, mental health, and neural network dysfunction.

Drs. Van Patten, Lee, and Jeste discuss the relationship between schizophrenia and aging in their chapter, providing additional conceptual framework for utilizing positive psychiatry for this severe mental illness. Rooted in the well-established approach of humanistic psychology, positive psychiatry provides a refreshing perspective to healthy aging. Positive psychiatry characteristics, such as resilience and increased family support, are associated with better emotional health in aging. This long overdue movement toward assessing and treating the whole individual (medical, emotional, psychosocial, etc.) has resulted in exciting research showing that higher positive psychiatry–related characteristics result in better functional outcomes and serve as a protective factor against the negative effects of illness in older adults.

The interplay of neurobiology, cognition, and psychiatric symptoms

The growing appreciation of neurobiology in mental illness has resulted in increased study of related biomarkers. In their chapter, Drs. Diniz and Butters review the current understanding of the biological mechanisms underlying cognitive impairment in late-life depression, and the complex neurobiological relationship between depression and neurotrophic cascades. Cognitive impairment is relatively common in older adults with depression and is associated for increased risk for dementia (Kaup et al., 2016). A recently published case study reinforces the importance of integrating neuropsychological findings and structural brain imaging in the assessment of suspected depression-based dementia, discussing the cognitive correlates of vascular-based depressive symptoms (Sheline et al., 2010; Tanner, Mellott, Dunne, & Price, 2015). In Chapter 8, Accelerated brain molecular aging in depression, Drs. Shukla and Sibille propose that age-related changes in gene expression are the driving process behind late-life depression and associated cognitive dysfunction, providing an eloquent model of molecular aging that has profound implications for late-life neuropsychiatry.

The assessment of cognitive functioning plays a pivotal role in understanding and appreciating the aging process. Neuropsychological assessment has predominantly relied upon paper and pencil tests to assess cognitive function. The field was originally founded to assess deficits in function, often as a method to localize lesions. With the advent of refined neuroimaging techniques, neuropsychology has pivoted to assisting in di...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Preface
• Chapter 1. Concepts and issues in mental health and aging
• Chapter 2. Epidemiology of selected mental disorders in later life
• Chapter 3. Culture and ethnicity in the mental health of older adults
• Chapter 4. Stress, mental health, and aging
• Chapter 5. Structural changes in the aging brain
• Chapter 6. Sleep-dependent cellular chemical changes in the aging brain
• Chapter 7. Biomarkers of cognitive impairment in late-life depression
• Chapter 8. Accelerated brain molecular aging in depression
• Chapter 9. Cognitive dysfunction in late-life psychiatric disorders: phenotypes, risk factors, and treatment targets
• Chapter 10. Suicide in late life
• Chapter 11. Anxiety and its disorders in old age
• Chapter 12. Bipolar disorders in older adults
• Chapter 13. Positive Psychiatry and successful aging in people with schizophrenia
• Chapter 14. Alzheimer’s disease and other neurocognitive disorders
• Chapter 15. Substance use disorders in the elderly
• Chapter 16. Sleep disorders and aging
• Chapter 17. Aging of persons with neurodevelopmental disabilities
• Chapter 18. Bereavement and grief
• Chapter 19. Neuropsychology with older adults
• Chapter 20. Integrative precision-medicine approach to cognitive assessment in older adults
• Chapter 21. Functional assessment in geriatric mental health
• Chapter 22. Psychotherapeutic interventions with older adults: now and into the future
• Chapter 23. Psychopharmacologic treatment
• Chapter 24. Technology-based mental health assessment and intervention
• Chapter 25. Community and home care for mentally ill older adults
• Chapter 26. Forensic and ethical issues
• Chapter 27. The economics of geriatric mental health care
• Chapter 28. The future of mental health and aging
• Author Index
• Subject Index