Mental Health in Elderly Research Paper

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This sample research paper on mental health in elderly features: 4800+ words (17 pages), an outline, and a bibliography with 10 sources. Assessment of mental health processes in the elderly can be particularly challenging, in part due to the fact that many assessment instruments were developed on younger populations and may not provide as accurate a picture in older populations, who vary greatly in their levels of cognitive, sensory, and motor abilities. In addition, many physical and mental illnesses in late life can present similar symptoms, and differentiating between the two is the focus of much of the assessment research in late life. Finally, the elderly may be less likely to disclose certain types of problems, and thus special techniques may be necessary to assess sources of psychological distress, including substance abuse and life events. However, less is known about what constitutes positive mental health in late life.

Outline

I. Heterogeneity in Older Populations

A. Age Influences on Validity and Reliability

B. Cohort Influences on Validity

II. Differentiating between Mental and Physical Health Problems

A. Differentiating Depression and Anxiety from Physical Health Problems

B. Differentiating Depression from Dementia

C. Distinguishing Schizophrenia from Dementia

D. Assessment of Behavioral Disorders

III. Assessing Factors Affecting Mental and Physical Health

A. Assessing Alcohol and Substance Abuse in the Elderly

B. Assessing Stress and Coping in Late Life

IV. Assessing Positive Mental Health

V. Summary

I. Heterogeneity in Older Populations

A. Age Influences on Validity and Reliability

As a developmental stage, late life encompasses more than 45 years, from roughly ages 65 to 110. Not surprisingly, there is an extraordinary amount of heterogeneity in this population. Some elders are physically and cognitively very healthy; others develop disabling chronic illnesses quite early on. Thus, it is often very difficult to make generalizations about ‘‘the elderly.’’ Not surprisingly, gerontologists have subdivided this developmental stage into three groups: the young-old, whose ages range from 65 to 79; the oldold (80 –99); and the oldest-old, or centenarians. Others differentiate between optimal aging, in which there is little decrement or even improvement in some functions; normal aging, in which there are some decrements for which the elderly can readily compensate to maintain adequate psychosocial functioning; and impaired aging, marked by declines in physical and cognitive function.

Thus, it is very important to understand the position along these continua of the elder or sample of elders to be assessed. In general, in the United States, the young-old are relatively healthy and it is likely that assessment techniques used in younger populations are quite adequate for this population. Indeed, if one attempts to use instruments developed for impaired elders in the ordinary young-old population, one rapidly runs into ceiling effects—nearly all elders will score in the top range, rendering criteria for predictive and discriminant validity nearly useless. In other words, if there is no variance on an instrument, it cannot be used to correlate with other measures or to distinguish between groups.

In contrast, for frail elders, who are more likely to be in the old-old age group, the use of standard instruments may pose a problem in both the reliability and validity of the data. Cognitively impaired elders may become confused when confronted with typical Likert scaling, and dichotomously scaled instruments may have more reliability and validity. (We have found that even elders in good condition generally dislike and mistrust the Procrustean bed of fixed response formats, and often need to be cajoled into translating their phenomenological experience into admittedly arbitrary numbers.) In addition, frail elders may have poor attention spans, requiring the administration of brief forms of standard instruments and/or multiple testing sessions over several days. Although elders in general respond as accurately on surveys as younger populations, it is unlikely that cognitively impaired elders can do so, and interviews are more likely to yield valid information.

Elders with visual impairments may have difficulty in reading questionnaires, requiring the use of larger fonts. In addition, we have found that scantron sheets which use relatively pale type faces with poor contrast (e.g., lavender script on cream-colored paper) are contraindicated with elders who have acuity problems.

Individuals with motor impairments, such as tremors associated with Parkinson’s disease or severe arthritis in the hands or wrists, may have difficulty in filling out questionnaires, and will require longer periods of time to complete them. For elders with severe forms of these illnesses, scantron forms are virtually impossible. Some researchers have switched to computer presentations of instruments which can aid in overcoming such sensory and motor deficits.

In general, we have found that frail elders do best in interviews in which the required responses to questions are available in both verbal and visual forms. If Likert scales are necessary for some instruments, then response cards, written in large fonts, which elders can hold and point to responses, are very helpful. Given that cognitively impaired elders often have difficulty in switching tasks, changing response cards is a good way of signaling that one task is done and that attention needs to be refocused on another.

However, interviews conducted in home settings may pose a special problem in assessing the elderly. In our experience, it is very difficult to interview just one member of an elderly dyad, especially in long-term married couples. Such couples may learn to compensate for memory problems by consulting with each other, and typically the non-target spouse will respond to questions, making accurate assessment of the target individual problematic. Thus, we have found it necessary to physically separate couples, either by giving the non-target elder an instrument to complete in another room, or by using pairs of interviewers to conduct simultaneous interviews, again in separate rooms.

B. Cohort Influences on Validity

Gerontologists distinguish among age, cohort, and period effects. In general, age effects are those which are solely due to an individual’s chronological age, cohort effects refer to historical impacts reflected in a person’s birth year or events experienced by a group of peers (e.g., the Depression), and period effects refer to larger social influences at the time of measurement. Neither cross-sectional nor longitudinal designs can adequately differentiate among these three types of effects, and only sequential designs, which follow multiple cohorts over different periods, can adequately differentiate these three types of effects. For any given effect to be accurately attributed to age, one must demonstrate that individuals of a given age are more likely to exhibit a particular response, regardless of what cohort they are in or the year in which they are assessed.

Age, cohort, and period effects also have implications for the validity of assessment instruments. For example, the validity of instruments used in older populations may be affected by cohort differences in language use and expression, a problem that has received relatively little attention in the assessment literature. One must be sensitive to whether the language used in any particular inventory is appropriate to the population under study. Indeed, the language used in older instruments is often more relevant to that used by older cohorts. For example, in the MMPI, there were several items which reflected older word usage (such as playing ‘‘drop the handkerchief’’). While the revised MMPI (MMPI-2) has eliminated anachronistic items, in 1991 Butcher and his colleagues found that nearly all of the age differences in the MMPI-2 still reflected either differing health statuses or cohort differences in language and experience (e.g., the use of marijuana was much less likely to be endorsed by older groups).

Many instruments commonly in use in psychology were developed on student populations, and, as such, may have poor ecological validity for the elderly. For example, a mastery or control instrument may include items about perceived fairness of grading practices or juggling work versus parenting roles. Certainly, any instruments used to assess mental health in the elderly must be sensitive to items that are more relevant to student or young adult experiences.

Less obvious sources of poor ecological validity may lie in cohort differences in reporting style. The current cohort of elders may be less willing to reveal emotional distress and/or use different terminology to refer these states. Older men in particular may be less comfortable in identifying stressors than younger men.

The possibility of response bias in the elderly has some interesting implications for the relative validity of diagnostic techniques. There is surprisingly little research available comparing the validity of self-report versus observer ratings in the elderly for specific illnesses. In general, observer ratings are thought to be more objective than self-report inventories, although there may be age-related biases in observer ratings, reflecting stereotypical biases about elders as more impaired, irascible, and so on.

A further problem is that clinical interviews often yield categorical classification, for example,full-blown depression versus none. To the extent that elders, even in clinical interviews, under-report symptoms, then such procedures may underestimate the existence of problems. For example, in 1992 Koenig and Blazer reviewed studies showing that the prevalence of major depression in the elderly, based upon clinical interviews, was about 1% (which is rather less than that reported for younger populations), but some 20% or more of older samples reported problems with negative affect on self-rated inventories, a figure muchmore comparable to younger samples. This is not to say that different criteria or cutoff points on standardized clinical assessment tools necessarily need to be developed, but rather that much more research is needed into this issue.

II. Differentiating between Mental and Physical Health Problems

Perhaps the issue which has received the most attention in the literature concerns the differentiation between mental and physical health.Many mental health scales include physical symptoms, which may be relatively uncommon in younger populations and indicative of psychological distress. However, in older populations, with their greater incidence of chronic health problems, such instruments may yield very high rates of false positives. Further, mental health problems often have physiological concomitants, and physical health problems can affect psychological states. Obviously, identifying the primary source of the symptoms is crucial in determining treatment options, although sometimes the only way in which to determine the precise etiology for a particular illness is to test different treatments. However, there are critical issues in differentiating anxiety, depression, and psychoses from a variety of physical health problems.

A. Differentiating Depression and Anxiety from Physical Health Problems

Self-report inventories of depression typically include many somatic complaints, such as fatigue, headaches, back and neck pain, constipation, and sleep disturbances. While in younger individuals these types of complaints may be indicative of depression, such symptoms are very common among the elderly. Thus, this inclusion of physical health symptoms in psychological assessment instruments may lead to Type I errors. On the other hand, there is some indication that depression in the elderly may be presented in terms of physical symptoms, and a relatively high proportion of medical visits to general practitioners by the elderly may be due to depression manifesting in physical complaints. Thus, screening for recent life events and/or changes in living conditions (see below) may be an important way for clinicians to determine whether bereavement or social isolation may be important factors underlying such visits.

On the other hand, many illnesses common to the elderly, as well as prescribed medications, may have concomitant symptoms of depression and anxiety. For example, elders are at increased risk for hypothyroidism, cardiovascular disease, and chronic obstructive pulmonary disorder, which may cause fatigue, sleep disturbances, and negative affect. Other disorders, such as myocardial infarctions, vitamin deficiencies, anemia, pneumonia, and hyper- and hypothyroidism, may present with symptoms of anxiety. Further, many medications commonly prescribed in the elderly, such as antihypertensives, may also create symptoms of depression. Thus, physical, mental, and social health are often tightly intertwined in the elderly, and multipronged assessment techniques may be necessary to adequately establish the etiology of symptoms of depression and anxiety in the elderly.

B. Differentiating Depression from Dementia

Some depressive symptoms mimic cognitive impairment, especially in the elderly. In particular, psychomotor retardation and memory lapses in the elderly are usually attributed to dementing processes, but actually may reflect depression. Pseudodementias can result from a wide variety of disorders, including nutritional deficiencies, prescribed medications, alcohol and substance abuse, and surgical procedures. Thus, assessment of the occurrence of problems of this type may be an important component in elders presenting with cognitive impairment. In turn, dementia is often associated with difficulty concentrating, loss of energy, and psychomotor slowing, even in the absence of depression. A number of different screening inventories have been developed to differentiate between these types of disorders.

In 1992, Newman and Sweet identified a number of different features which may distinguish depression from dementia. Depression often has a rapid onset while dementia often has a gradual one. In addition, there may be differences in both patient and familial awareness of the problems, with recognition greater in depression-related cognitive impairment than in problems related to dementia. Patients who are depressed may be able to provide greater detail about their impairment and to manifest subjective distress, while dementing patients may have vague, nonspecific complaints and may be more likely to conceal cognitive deficits. Depressed patients typically show poor motivation and give up easily on tasks, while dementing patients may struggle with tasks.

In addition, there are a number of differences between the two groups in both cognitive testing and neurological examination. For example, depressed patients typically have problems with both recent and long-term memory, and report poorer concentration than actual knowledge testing, whereas dementia patients typically have much worse recent than longterm memory deficits and general knowledge is worse than concentration skills. Finally, depressive patients typically demonstrate no problems with specific neurological testing, while dementing patients typically present with dyspraxias and agnosias, and show abnormal CAT scans, with increased ventricular size. In addition, the administration of antidepressive medications may be one way to distinguish depressionrelated pseudodementias from true dementias resulting from neurological disorders.

C. Distinguishing Schizophrenia from Dementia

While the onset of schizophrenia typically occurs in adolescence or young adulthood, schizophrenia may also occur in late life. Schizophrenia with a late life onset is often called paraphrenia, and may occur in individuals who have a history of eccentricity and are socially isolated. However, dementia can also produce hallucinations and delusions, and thus, like depression, it is important to distinguish between the two conditions.
Given that late-life onset of schizophrenia is relatively rare, very few systematic studies have been conducted. However, neuropsychological assessment studies have been done, and, in many cases, it is possible to rule out dementing processes.

D. Assessment of Behavioral Disorders

Particularly disturbing concomitants of the cognitive and affective disorders prevalent in late life are behavioral disturbances. These disturbances, including wandering, sleep disruptions, verbal and physical aggression, and hallucinations and delusions, may have serious impacts on the quality of life for both elderly individuals and their caretakers. Patients who exhibit such behaviors may be labeled as ‘‘problems’’ by nursing home staff and then regularly given psychotropic medication to control their behavior, which can result in a variety of adverse physical, cognitive, and affective side effects. While there have been regulatory efforts to decrease the use of psychotropic medications in nursing homes, paradoxically, this regulation can result in increased use, as nurses are given less discretion and physicians must prescribe the use of such drugs on a regular basis.

In 1994, Teri and Logsdon reviewed the variety of scales which have been developed fairly recently to assess behavioral disturbances. These typically are observational measures, and may be administered by researchers, clinicians, nurses, or caregivers. A major purpose of these scales is to quantify the frequency and severity of such disturbances to devise appropriate treatment strategies. Detailing the exact pattern of aggressive and disruptive behavior may result in a more objective picture of the actual problems created by such patients, facilitate behavioral intervention, and result in less reliance on psychotropicmedications.

III. Assessing Factors Affecting Mental and Physical Health

There are a variety of factors which can affect physical and mental health in late life. In terms of behavioral factors, alcohol and substance abuse, as well as stress, are two of the most important ones.

A. Assessing Alcohol and Substance Abuse in the Elderly

In the late 1960s Cahalan and his associates developed a survey assessment instrument for alcohol consumption and problems. It assessed alcohol consumption using three different scales: (1) the usual number of drinks of beer, wine, and distilled spirits consumed ‘‘nowadays,’’ as reported in drinks per day, week, month, or year; (2) the number of drinks of beer, wine and distilled spirits consumed the day before completing the questionnaire; and (3) the regularity of alcohol consumption on specific days of the week. For example, a respondent may indicate that, in a typical week, he or she drinks one glass of wine during the evenings and two drinks each on Friday and Saturday night. Thus, this individual, on average, drinks nine drinks a week, which then usually is translated into drinks per year.

Independently of consumption, respondents indicate the frequency (e.g., never, once per week, month, or year) of experiencing alcohol problems. These items assess the frequency with which alcohol affects physical, psychological, or social functioning. In general, convictions for drunk driving and alcohol-related traffic accidents are weighted more heavily than other types of problems. Although they reflect some components of a DSM-IV diagnosis of alcoholism, they do not permit such a diagnosis, which requires the use of a diagnostic interview.

The shortest and simplest self report of alcohol abuse is the four-item CAGE instrument, in which a positive response to two or more of the items suggests alcohol abuse. The items assess feeling that one should drink less, being annoyed by others’ criticizing one’s drinking, feeling guilty about drinking, and drinking in the morning. The items have good face validity, yet this instrument does not appear to be sensitive in older populations. The Michigan Alcoholism ScreeningTest (MAST) for older adults is a much longer (24-item) instrument that has been validated on the hospitalized elderly but may not be practical for screening outside hospitalized populations. It should be noted that other versions of the MAST have not been equally valid in all populations tested.

The use of self-report surveys of alcohol consumption and problems may prove difficult, especially with the elderly. However, for the general population, Midanik concluded in 1988 that ‘‘the validity of self-reports is not an either/or phenomenon.’’ There is no ‘‘gold’’ standard against which to compare selfreports, only a variety of ‘‘lead’’ standards such as collateral reports, diaries, official records, laboratory tests, or interviews. All of these methods assess overlapping but nonisomorphic aspects of an individual’s alcohol use. Sobell and Sobell noted in 1990 that the relevant issue is the extent of discrepancy among sources of information that are being used to investigate a given research question. The latter observation may be especially relevant for the elderly.

Tobacco, alcohol, and prescription drugs (usually anxiolytics) are the most abused drugs in the elderly. Indeed, alcohol consumption both reduces thiamine uptake and interacts with prescription drug use, a fact that is further complicated by the reduced capacity of elderly persons for clearing such drugs. Thus, use of both types of substances may carry a risk for health problems that increases with age. Moreover, the elderly may not recognize that their relatively nonproblematic levels of consumption at younger ages may cause problems in later life.

While drinking has been shown to decline with age, this may not be a reliable predictor of future trends since recent research has shown that changes in drinking patterns appear to be more closely associated with period rather than age effects. These considerations may render assessment of risk for problem drinking (with its attendant drug interactions) more difficult in the elderly.

In 1997, Atkinson argued that the relatively lowreported rates of alcoholism in those over the age of 60 (no more than 2% in men and less than 1% in women) may underestimate the actual prevalence of problems) largely due to a failure to accurately report consumption and problems in surveys. The ‘‘discrepancy problem’’ may be more pertinent among the elderly than in younger populations. Thus, there may be special difficulties with self-report in the elderly, with a problem/reported problem ratio perhaps increasing with age. This is further complicated by cohort effects, with younger cohorts more willing to acknowledge problems than older ones, if such cohort differences are maintained in later life.

Excluding daily blood alcohol level testing, there are several reasonable supplements to self-report in the elderly. First, there is a pattern of cognitive deterioration associated with alcohol abuse in the elderly that is distinct from that associated with senile dementias such as Alzheimer’s and even Korsakoff’s Syndrome (which involves irreversible brain damage due to longterm severe alcohol abuse). This pattern is summarized in DSM-IV as involving deficits in memory, language, motor functions, object recognition (without organic motor or sensory impairment), and abstract thinking and planning. Evidence has supported this diagnostic approach with an additional strong finding that name-finding was almost completely spared in alcohol-related dementias, in contrast to Alzheimer’s Disease, in which dysnomia is pronounced.

Second, and perhaps most helpful, are in-home assessments. In addition to standard consumption interviews and listing the prescriptions and home remedies that the elderly use, other data and relatively unobtrusive observations can be employed. These include a history of falls, grooming, odors present in the house (also, obviously, useful for an assessment of tobacco use), bruises at the level of furniture, tremors, incontinence, and many others (many of which could be associated with non-alcohol-related dementias or depression). Naturally, such an assessment would require considerable training and would obviously be available only for that minority of the elderly who receive home care from outside agencies.

Unfortunately, there is no good way of assessing the dependence on prescription tranquilizers (principally benzodiazepines) in the elderly unless withdrawal symptoms, such as extreme anxiety and irritability, occur since dependence is not typically associated with dose increase. Such dependence is more frequent among elderly women than men. Signs of toxicity from long-term use are easily mistaken for other disorders of the elderly, such as memory loss and other cognitive impairments, as well as problems with mobility. It is likely that alcohol and drug abuse may reflect the levels of stress in elders’ lives.

B. Assessing Stress and Coping in Late Life

There are several different ways of assessing stress, including traumatic events, life events, chronic role strain, and daily stressors or hassles. In the last decade, it has rapidly become apparent that both type and frequency of stressors change with age. While early studies suggested that the number of stressful life events decrease with age, perusal of the types of events typically found on early life event scales reveal that many are far more relevant to younger populations than to older ones (e.g., marriage, divorce, changing jobs, imprisonment). Several instruments are now available that assess life events that are more relevant to older populations such as caretaking for spouse and parents, institutionalization of parent or spouse, death of a child, child’s divorce, problems with grandchildren, and the like. These instruments are less likely to show a decrease in stressful life events with age.

However, the number of daily stressors does decrease with age, most probably due to the decline in the number of social roles. For example, most older adults have relinquished active parenting and work roles, the source of the majority of hassles in mid-life. While there is a concomitant increase in the number of hassles associated with both health problems and avocations in retirement, for most older adults, these typically do not generate as many hassles as do work and childrearing roles.

In part, this may be due to changes in the nature of stress in late life. Stress in earlier life is more likely to be episodic in nature, such as children’s crises or problems at work, whereas stressors in late life may be more likely to be chronic, for example, managing chronic illnesses or caregiving for an ill spouse. If chronic problems are successfully managed, they may not be perceived as ‘‘problems’’ per se. An 80-year-old with multiple health problems may well assert that he or she has had no problems in the past week, despite obvious impairments requiring careful management. Thus, among the old-old, interviews may be better assessments of stress than self-report instruments.

However, the decrease in stress reporting may also be due to age-related changes in the way individuals cope. In some ways, older people are better copers, in that they are less likely to use escapist strategies such as alcohol, drugs, or wishful thinking—or perhaps individuals who survive until late life are less likely to use escapist strategies. However, the old-old may be more likely to use denial as a coping strategy. Denial of the severity of health problems, for example, may be a palliative strategy, as long as appropriate instrumental actions are taken, such as adhering to a medical regimen. However, the old-old are often reluctant to admit problems for fear that they will be institutionalized, with all that entails, including separation from spouse and loved ones and the loss of control. Thus, they may deny and/or hide problems, even those which could be adequately treated in the home, which can lead to worse problems, greatly increasing the risk of institutionalization. Thus, accurate assessment of problems in the elderly are crucial to both their treatment and may permit successful home treatment and forestall institutionalization.

IV. Assessing Positive Mental Health

Mental health is not simply the absence of symptoms, but entails positive functioning aswell. Unfortunately, positive mental health has received less attention in the elderly, with the possible exception of one of its dimensions, life satisfaction.

Despite the widespread dissemination of Erikson’s theory of ego development in adulthood, only a handful of scales have been developed to assess generativity and ego integrity. The most extensive scale development on positive mental health in late life has been done by Ryff and her colleagues in the 1980s. They developed measures of complexity, generativity, integrity, and interiority, as well those that assess selfacceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. Although Ryff’s scales are correlated with the Big Five personality factors (neuroticism, extraversion, openness to experience, conscientiousness, and agreeableness), they correlate independentlywithpositive affect, suggesting that they assess more than just the standard personality dimensions. It remains to be seen whether these scales will enjoy widespread use as indicators of positive mental health in the elderly.

V. Summary

In summary, assessing mental health in the elderly requires attention to a number of factors, including the age and functional ability of the elder and whether or not the instrument used has adequate reliability and validity for older populations. While elders may be more or less accurate at reporting symptoms as younger groups, the crucial assessment issue appears to be differentiating between possible sources of the problems. Further, more research needs to be done in assessing positive mental health in the elderly.

Bibliography:

  1. Aldwin, C. (1994). Stress, coping, and development: An integrative approach. New York: Guilford.
  2. Atkinson, R. M. (1997). Alcohol and drug abuse in the elderly. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (2nd ed., pp. 661–688). Oxford: Oxford University Press.
  3. Garland, J. (1997). Psychological assessment and treatment. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (2nd ed., pp. 246 –256). Oxford: Oxford University Press.
  4. Howard, R., & Levy, R. (1997). Late-onset schizophrenia, late paraphrenia, and paranoid states of late life. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (2nd ed., pp. 617–631). Oxford: Oxford University Press.
  5. Newman, P. J., & Sweet, J. J. (1992). Depressive disorders. In A. E. Puente & C. R. Reynolds (Eds.), Handbook of neuropsychological assessment: A biopsychosocial perspective (pp. 263– 308). New York: Plenum.
  6. Pachana, N. A., Gallagher-Thompson, D., & Thompson, L. W. (1994). Assessment of depression. In M. P. Lawton & J. A. Teresi (Eds.), Annual Review of Gerontology and Geriatrics, Vol. 14 (pp. 234 –256). New York: Springer.
  7. Rabins, P. V. (1992). Schizophrenia and psychotic states. In J. E. Birren, R. Bruce Sloane, & G. D. Cohen (Eds.), Handbook of mental health and aging (2nd. ed., pp. 464 – 479). San Diego: Academic Press.
  8. Ritchie, K. (1997). The development and use of instruments for the psychological assessment of older patients. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (2nd ed., pp. 232–245). Oxford: Oxford University Press.
  9. Ryff, C. D., & Essex, M. J. (1991). Psychological well-being in adulthood and old age: Descriptive markers and explanatory processes. In K. W. Schaie (Ed.), Annual Review of Gerontological and Geriatrics, II, 144 –171. New York: Springer.
  10. Sheikh, J. I. (1992). Anxiety and its disorders in old age. In J. E. Birren, R. B. Sloane, & G. D. Cohen (Eds.), Handbook of Mental Health and Aging (2nd ed., pp. 410– 432). San Diego, CA: Academic Press.

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