CHAPTER 11

Mental Health Issues and Treatment

Lecture guidelines

The main point of this chapter is to orient students to the need to think about psychopathology in later adulthood as a real concern that affects the lives of many people in the U.S. A second major point is that the majority of older adults do not have psychological disorders and, contrary to what students might expect, there are fewer rather than more older adults with diagnosed depression. However, a caveat to this statement is the fact that many older adults under-report their symptoms, and the actual prevalence figures may not represent accurately the extent of psychological problems in this age group. These and related diagnostic issues are interesting and worthwhile to present and discuss to the class. Similarly, there are many inherently fascinating and important issues involved in the psychological treatment of older adults. This field is relatively new within psychology, but it is growing very quickly. Instructors who learned about the field of psychopathology in later life some years ago will be encouraged by the burgeoning of new methods and research in this area. Fortunately, students are inherently interested in the topic of abnormal psychology, so there is a good chance that they will be motivated to do the reading on their own and to come to class prepared to discuss both theoretical and clinical issues.

Videos and films

The specific area of mental health and aging is not one that is well represented in either documentaries or popular media. There are a few documentaries produced by television news magazines that focus on certain issues (e.g. alcohol use in later life), but other than that, the choices are limited. One example is the A&E series called “Hoarders” which included several episodes focusing on older adults. The topic of financial abuse is often covered in news programs. Students can also be enlisted to submit their own examples from the media that highlight potential financial scams targeting older adults (e.g. https://www.mycreditunion.gov/fraud-prevention-center/scams/older-adults and https://www.cnbc.com/2019/10/13/elder-financial-abuse-is-a-multibillion-dollar-problem.html).

Discussion Questions

Psychological disorders in adulthood

Do you agree with the text definition of psychological disorder? Why or why not?

What alternatives might you suggest to the current definition of psychological disorder?

Do you think that people should receive diagnoses for psychological disorders? Why or why not?

Why is it important to distinguish prevalence from incidence?

Why do clinicians have difficulty diagnosing mood disorders in older adults?

How can mental health professionals be better trained to diagnose anxiety disorders in older adults?

What do you think life is like for an older adult who has had schizophrenia for most of his or her adult years?

What happens to an older person with delirium or amnesia who is misdiagnosed with Alzheimer's disease?

Why do you think that substance use rates are so high in the U.S.?

What factors might account for changes in substance use in people over the age of 35?

Do you think that rates of substance abuse and dependence will increase or decrease as current cohorts of young people move through adulthood?

Elder abuse

Why does elder abuse occur? How is it related to other problems in social treatment of older adults?

Thinking of issues discussed in Chapter 9 (adult child-parent relationships), what factors might account for the high frequency of children as abusers of their aging parents?

Suicide

What are the possible reasons that people who survive to advanced old age would wish to end their lives?

Why is it that health care providers often miss the diagnosis of suicidality in older adults?

Treatment issues in mental health care

Why should clinicians consider differentiating their treatment approaches to older adults from those used for younger adults?

What sorts of training would seem necessary to become a geropsychologist?

Which type of assessment measures would you use if you were a clinician? Why?

What types of research are needed to refine and improve assessment procedures for diagnosing psychological disorders in older adults?

What might be the justification for giving ECT to an older adult?

How can clinicians be better trained to provide therapy to older adults?

Why is evidence-based practice so important in the treatment of psychological disorders?

Multiple Choice questions

AgeFeed

Warning signs older adults

According to AgeFeed, which behavior might be of concern for mental health if shown in an older adult?

1. showing interest in watching crime dramas
2. selling out-of-date appliances
3. wanting to move from a house to apartment
4. engaging in new, risky behaviors

Warning signs older adults

Which of the behaviors, based on the list in AgeFeed, ____________would not be of concern if engaged in by an older adult.

1. Often experiencing feelings of restlessness.
2. Making sudden, poor, financial decisions.
3. Deciding to change some habits and daily routines.
4. Repeatedly turning down invitations to family events.

Psychological disorders in adulthood

Ageism by mental health providers

Ageism toward older adults by mental health service providers might take which of the following forms?

1. requesting further follow-up for an older patient who seems depressed
2. reacting to older adult patients as they would to family members
3. providing specialized assessments for older patients with memory problems
4. asking family members for information about an older patient

DSM-5 not designed for older adults

A psychologist who specializes in treatment of older adults finds it at times frustrating to use the Diagnostic and Statistical Manual (DSM-5) in working with these patients because it:

1. only covers medical rather than psychiatric conditions.
2. has very little information specifically on aging.
3. cannot be used as a basis for insurance reimbursements.
4. is used by a small portion of the mental health community.

Mobility limitations and depression

Found to contribute to major depressive disorder in older adults, which condition might be overlooked by psychologists conducting an assessment?

1. excessive amounts of vitamin D
2. comorbidity with bipolar disorder
3. mobility limitations
4. psychosocial stressors such as bereavement

Acute stress disorder

A 77-year-old woman’s apartment was destroyed in a fire started by a neighbor’s candle. In the 3 weeks since the fire, she remained on the alert for anything that could cause a fire but her nightmares about the fire have since ended. Her symptoms would suggest that she experienced which type of disorder?

1. specific phobia
2. major depressive
3. acute stress
4. late-onset stress

LOSS symptoms

One of the key symptoms of LOSS, as shown particularly in older veterans, is the experience of:

1. depression after the death of a spouse.
2. unwillingness to seek treatment.
3. increased memories about an earlier traumatic experience.
4. extreme fear of objects that contain small holes.

Depression vs. neurocognitive disorder

An older adult client is being seen in a clinic to evaluate whether she has depression or a neurocognitive disorder. One indication that will help a clinician in making the diagnosis is that if she is depressed, she will show which behavioral tendencies?

1. progressive cognitive declines over time
2. cognitive symptoms before depression symptoms
3. exaggerate the extent of her memory loss
4. not respond to psychotherapeutic intervention

Psychopathy

Difficulty:

The personality trait of ___________, characteristic of people with antisocial personality disorder, tends to remain stable over the course of adulthood.

1. narcissism
2. psychopathy
3. impulsiveness
4. extraversion

Depression and diabetes

Older adults who have depressive symptoms and diabetes have higher mortality rates due to increased ______________ responses associated with C-reactive protein.

1. periodontal
2. hyperthermia
3. inflammatory
4. arthritic

Bipolar disorder and lifestyle

Researchers who study bipolar disorder in older adults emphasize which lifestyle change as part of treatment?

1. avoiding smoking and alcohol
2. cutting down on exercise
3. discontinuing lithium
4. sleeping fewer hours

Social anxiety disorder

The staff of an assisted living facility is concerned that a new resident refuses to eat in the public dining spaces out of concern about being perceived as a messy eater. Based on this behavior, it is possible that this resident is experiencing __________ disorder.

1. agoraphobia
2. obsessive-compulsive
3. social anxiety
4. borderline personality

Anxiety disorders prevalence

The estimated 12-month prevalence of anxiety disorders in older adults is:

1. 17.2
2. 8.3
3. 3.8
4. 11.5

Agoraphobia

Which of the following anxiety disorders shows the highest prevalence in adults 65 and older?

1. social anxiety disorder
2. agoraphobia
3. general anxiety disorder
4. animal phobia

OCD

Among older adults, the percent who show symptoms of obsessive compulsive disorder is estimated at:

1. 14.5
2. 17.6
3. 21.0
4. 2.9

Hoarding disorder

A psychologist suspects that an older adult has developed hoarding disorder when the individual is unable to dispose of:

1. photo albums of family members.
2. holiday decorations and wrapping paper.
3. a favorite set of stainless steel pots and pans.
4. empty cans, old newspapers, and food remnants.

PTSD in combat veterans

Military veterans exposed to combat during their tour of duty have a _______% prevalence rate of post-traumatic stress disorder in their later adult years.

1. 17
2. 35
3. 6
4. 24

Schizophrenia older adults

Compared to younger adults who develop schizophrenia, in older adults _____________ seem to play a greater role.

1. genetic factors
2. delusions
3. psychosocial stressors
4. lifestyle choices

Illicit drug use

By the age of 65 years and older, approximately ____% of the population used illicit drugs in the U.S. as of 2018.

1. 17.1
2. 5.7
3. 14.9
4. 34.3

Illicit drugs 18-25 year olds

Among 18-25 year olds, approximately ____% of the population used illicit drugs in the U.S. as of 2018.

1. 17.1
2. 5.7
3. 14.9
4. 34.3

Prescription drug abuse

As of 2018, what percent of adults 65 and older in the U.S. abuse prescription drugs?

1. 3.4
2. 0.3
3. 1.6
4. 2.2

Binge drinkers 65+

Among adults 65 years and older, what percent are considered binge drinkers?

1. 9.7
2. 30.9
3. 7.1
4. 2.2

Retirement communities and alcohol abuse

In which type of setting are professionals concerned about high rates of alcohol abuse by older adults?

1. shopping center
2. retirement community
3. public transit station
4. single-family dwelling

Crime statistics

According to statistics from Canadian crime reports, criminal acts involving _________have much higher prevalence rates in young adulthood, after which there is a sharp drop-off.

1. common assaults
2. fraud
3. criminal harassment
4. disturbing the peace

Boorderline personality disorder

Older adults with borderline personality disorder continue to show high levels of which quality into later life?

1. emotional instability
2. impulsivity
3. fear of abandonment
4. problems in relationships

Antisocial personality disorder

The most common pattern of antisocial personality disorder in adulthood is referred to as:

1. adolescence limited
2. late life persistent
3. midlife prevalent
4. late life emergent

Schizophrenia and mortality

Research on schizophrenia in adults from 20 to 64 showed increased risk of mortality due to:

1. overdoses of antipsychotic medications.
2. use of tobacco, alcohol, and other drugs.
3. institutionalization in psychiatric facilities.
4. being victims of violent homicides.

Agoraphobia symptoms

People who have the anxiety disorder known as agoraphobia fear what type of situation?

1. having a panic attack without being able to escape.
2. being in the upper story of a tall skyscraper.
3. confined in small spaces with no light.
4. speaking in front of others in public places.

Depression symptoms

The symptoms of depression in older adults include which of the following?

1. feelings of worthlessness.
2. extreme fear of being alone.
3. generalized feelings of worry.
4. the inability to part with useless objects.

Obsessive-compulsive personality disorder

People with obsessive-compulsive personality disorder in later life tend to experience which additional psychological attribute?

1. high conscientiousness
2. adaptability to change
3. depression
4. disinterest in work

Elder abuse

Adult Protective Services

When Adult Protective Services was mandated by Title XX of the Social Security Act in 1975, what provisions for its funding were made by Congress?

1. uniform state regulations
2. private health insurance
3. little or no federal aid
4. public health insurance

Types of elder abuse

The five types of elder abuse are physical, sexual, psychological, financial, and:

1. criminal.
2. neglect.
3. health care.
4. judicial.

Elder abuse signs

Healthcare providers should inquire about the possibility of __________ if they notice unexplained injuries in their older adult patients such as bruises and scars.

1. financial fraud
2. elder abuse
3. bipolar disorder
4. depression

Financial abuse

The daughter of a retired office worker begins to get suspicious when her mother says that the Internal Revenue Service called, demanding payment of $10,000 for back taxes. It is likely that the call was an attempt at:

1. preventing imprisonment.
2. emotional abuse.
3. fraud protection.
4. financial abuse.

Elder abuse treatment

Evidence-based approaches to preventing and treating elder abuse suggest that there may be promise in focusing on:

1. relocating victims.
2. financial planning.
3. work with caregivers.
4. exposure to trauma.

Suicide

Suicide rates

The suicide rate is highest for which segment of the U.S. population?

1. women 45-54
2. men 15-24
3. women 55-64
4. men 65 and older

Suicide method

In the U.S., the majority of suicides among men in later life involve which means of death?

1. hanging
2. prescription drugs
3. firearms
4. opioids

Cancer and suicide

Older adults at risk of suicide are likely to suffer from higher rates of which chronic health condition?

1. cancer.
2. diabetes.
3. COPD.
4. hearing loss.

Treatment

Geropsychology guidelines

The Geropsychology Guidelines of the APA suggest that clinicians should:

1. treat older adults in the same way as they do children.
2. refer all assessment services out to physicians.
3. gain knowledge about the aging process.
4. choose assessment tools shown to work with young adults.

Assessments for older adults

Geropsychologists recommend that clinicians make which of the following adjustments when conducting an assessment with an older adult?

1. Present materials in large print and avoid outside distractions such as noise.
2. Make them feel pressured to respond so that they will perform at their maximum.
3. Conduct testing in a single session so that treatment can move to the next phase.
4. Avoid making special exceptions for older clients which would bias the results.

Mini-Mental State

The Mini-Mental State Examination for assessing older adults involves questions that include:

1. naming close family members.
2. completing a jigsaw puzzle.
3. ratings of current mood.
4. remembering three words.

Evidence-based practice

In ____________________, clinicians plan interventions with older adults that take into account such factors as available research, the individual’s cultural background, and specific diagnosis.

1. differential diagnosis
2. biopsychosocial treatment
3. evidence-based practice
4. problem-solving therapy

ECT older adults

One of the known risks of electroconvulsive therapy (ECT) for older adults is that it can cause:

1. chronic disorientation.
2. short-term memory loss.
3. withdrawal and dependence.
4. accidental overdose.

Cognitive-behavioral therapy

In cognitive-behavioral therapy, the “cognitive” component involves teaching clients to:

1. be aware of and try to change negative self-thoughts.
2. learn to pay more attention to their surroundings.
3. find better words to tell other people how they feel.
4. identify which people tend to cause them the most stress.

PTSD treatment

An effective treatment for people with PTSD combines relaxation therapy with __________ therapy, in which they are guided in mentally re-enacting a traumatic experience.

1. problem-solving
2. exposure
3. antipsychotics
4. mindfulness

Fear of falling

Research suggests that combining cognitive-behavioral therapy with ____________ can be helpful in treating older adults with fear of falling.

1. antidepressants
2. electroconvulsive therapy
3. antipsychotics
4. exercise

Psychotherapy alone (evidence-based)

Research on evidence-based treatments for older adults suggests that the most effective approach should involve, as a first step:

1. medications alone.
2. medications plus psychotherapy.
3. in-patient observations.
4. psychotherapy alone.

Mindfulness

An older woman who is experiencing depression along with insomnia and back pain is advised by her healthcare professional to seek mindfulness training in which she:

1. can be taught take her problems and solve them one-by-one.
2. practices improving her long-term memory with mental exercises.
3. will learn to focus on the details of her experiences, including pain.
4. exposes herself to situations that have caused her pain in the past.

Serious Mental Illness

Highest SMI rates

The highest rates of serious mental illness (SMI) are found among which age group?

1. 65 and older
2. 50-54
3. 35-39
4. 18-25

SMI 65+ women

The rate of serious mental illness (SMI) in adult women 65 and older is:

1. 7.1.
2. 2.1
3. 9.2
4. .8.

Short Answer Questions

Psychological disorders in adulthood

1. Describe the four effects of ageism on service provision to older adults.
2. What are four conditions in older adults that can contribute to the development of depression?
3. Why might agoraphobia be the most prevalent anxiety disorder affecting older adults?
4. What factors contribute to hoarding in older adults?
5. What are the three most commonly used illicit substances by older adults?
6. How does antisocial personality disorder change in later adulthood?

Elder abuse

1. What are the five forms of financial abuse of elders?
2. Which government programs serve to protect older adults from abuse?

Treatment Issues: Health and mental health care

1. What are the five basic components of the Pikes Peak Model of Geropsychology Training?
2. What are the three principles of evidence-based practice?
3. What are the three benefits of cognitive-behavioral therapy for older adults?

Essay questions

1. You are a clinician seeing an 86-year-old white male complaining of shortness of breath, stomach upset, problems with memory, and difficulty sleeping. This client has recently experienced the loss of his wife.
   1. What assessment measures would you use?
   2. What are the possible diagnoses you would consider?
   3. What possible serious difficulties might you envision for this client in terms of risk? How would you assess this risk?
   4. Describe the alternative treatments you would recommend for this client.
2. An older relative of yours received a letter informing her that she has won a lottery; the letter also asks her to call in her bank account information to receive the winnings. The relative has never entered the lottery and isn’t sure what to do but she is very excited about receiving the money. What advice would you give her to prevent her from experiencing financial abuse?
3. Analyze the possible reasons for elder abuse. If you were the director of a social services agency how would you train your staff to recognize and intervene in cases of abuse?