Gerontological Clinical Psychology Research Paper

1. Proficiency In Clinical Geropsychology

Until recently, outpatient mental health care services have been underutilized by older adults, despite 1975 legislation mandating specialized services for mentally ill older adults within community mental health centers. The majority of the elderly who receive mental health services are seen as inpatients during hospitalization in a psychiatric hospital or a nursing home. Possible explanations for this phenomenon include the idea that there is stigma attached to receiving mental health services within this cohort, but this concern has not been supported in limited research (Rokke and Scogin 1995). Alternatively, mental health professionals have historically displayed ‘professional ageism’ dating back to Freud, who was pessimistic about psychological change or the benefits of therapy in later life. Finally, Medicare reimbursement for psychological services in the United States is very limited. The majority of the money spent goes toward psychopharmacology as opposed to psychotherapy, reducing the availability of psychological services.

However, patterns of usage of psychological services by the elderly are changing. Successive cohorts of older persons have higher levels of education and a greater acceptance of psychology. Rokke and Scogin (1995), for example, showed that older adults considered cognitive therapy to be more credible and acceptable than drug therapy for depression. It is likely that psychologists could be much more active in reaching out to older adults to provide services, and that they can expect an increasingly positive welcome.

As more older adults seek or accept psychological services, psychologists must be prepared to meet this need. To address issues of responsibility and competency in providing such care, the American Psychological Association (APA) has approved Clinical Geropsychology as an area of special proficiency. Guidelines addressing the needed competencies for proficiency in clinical geropsychology have been drafted and widely promulgated (APA Interdivisional Task Force 1999). In this document, 13 areas of knowledge and skills that define proficiency knowledge in Clinical Geropsychology are specified, as listed below and then reviewed in more detail:

(a) Research and theory in aging

(b) Cognitive psychology and change

(c) Social/psychological aspects of aging

(d) Biological aspects of aging

(e) Psychopathology

(f ) Problems in daily living

(g) Sociocultural and socioeconomic factors

(h) Assessment

(i) Treatment

( j) Prevention and crisis intervention services

(k) Consultation

(l) Interface with other disciplines

(m) Special ethical issues in providing services to the aged.

1.1 Research And Theory In Aging

It is important for psychologists to understand aging in a broad context, as a psychological, biological, and social process. Further, some research methodology issues are especially relevant to aging, in particular understanding the impact of cohort or group differences by age.

1.2 Cognitive Psychology And Change

Changes in cognitive and behavioral function are common with aging; most such changes are relatively minor, such as increased difficulty with short-term memory or recall memory. However, the prevalence rate of more severe cognitive changes, indicating dementia, also increases with age. At age 65 only 1 percent of the population have dementia, compared to 30–35 percent by age 85 and 50 percent by age 90. The concept of dementia has evolved from the nonspecific ‘organic brain syndrome’ to a more precise picture of a complex disorder encompassing several distinctive disease entities, each with its own specific set of treatment implications. More detail is provided on cognitive changes with age under proficiencies Sect. 1.5, Psychopathology, Sect. 1.8, Assessment, and Sect. 1.9, Treatment.

1.3 Social Psychological Aspects Of Aging

Aging is a personal process and a social process that occurs in a context of familial, cultural, and political elements. As reviewed above, the demographics of aging reflect a changing social context of aging. This changing context also affects intergenerational relationships, the nature of relationships in later life (e.g., since more adults are living to old age, larger peer networks of older adults exist than in prior generations), and perceptions of aging.

1.4 Biological Aspects Of Aging

Important biological aspects of aging include normal biological aging changes, abnormal changes and disease, lifestyle and behavioral factors in health, chronic and terminal illness, and pharmacological issues. Chronic health problems (e.g., arthritis, hypertension, hearing impairment, heart conditions) are often experienced by older adults. Many of these physical conditions are associated with chronic pain, and psychologists can employ strategies to help with pain management. Because of health concerns, many older adults are given medications, often without good explanation of the importance of taking the medication routinely, resulting in erratic usage. Psychologists can work with older adults to encourage consistent use of prescribed medication, to help them understand its importance, and to help identify the health-related belief system of older adults and incorporate those beliefs into the medical regimen. Insomnia, particularly sleep-maintenance insomnia, is an age-related and debilitating condition. Behavioral procedures for treating insomnia in older adults are more effective than relaxation training or imagery training. In addition, they offer the ability to avoid or discontinue sleep-inducing medications that can cause iatrogenic problems (Morin et al. 1999).

1.5 Psychopathology And Aging

The best estimate of the rate of psychopathology in the older population in the United States is approximately 22 percent (Gatz and Smyer 1992), but there are huge differences among different groups of older adults and across different types of psychopathology. Specifying the prevalence and incidence of psychopathology in older adults is complicated by problems with methodology and design. Most studies on older adults do not take racial and/or cultural distinctions into account in the manifestation of disease. Finally, studies do not always agree on diagnostic criteria and terminology, thus yielding imprecise estimates. For all disorders, the accepted criteria for older adults are exactly the same as those for younger adults using the Diagnostic and Statistical Manual-IV (DSM-IV ) diagnostic system. However, interpreting some of the criteria for each disorder may be complicated by other aspects of the aging process. In the following subsections, some of the most common mental disorders will be examined and, when appropriate, issues that make diagnosis more complex in older adults will be addressed.

Older adults have a lower rate of major depressive disorder than middle-aged adults; however, there is a higher prevalence of subclinical symptoms in older adults (Gatz et al. 1996). Data from a number of studies indicate that across the adult life span, the highest depression scores are found among younger adults and persons 75 years and older. As with younger adults, women show higher rates of depression than men, although studies suggest that by age 80, men and women have an equal rate of depressive symptomatology. A subset of depressed older adults that warrant particular concern is white men aged 60–85, particularly those with medical illness or living alone; this group has the overall highest rate of suicide.

Life events, such as deaths of loved ones and change in residence, have shown an inconsistent relationship with depression. Although these negative life events occur more commonly in older adults, some scholars argue that older adults have experienced a number of stressors earlier in life, and/or that older adults are better able to cope and regulate emotion more effectively (e.g., Carstensen and Charles 1998), causing the relationship between negative life events and depression to be less strong among older adults. Physical illness, although a statistically major risk factor for depression, probably is not the causal variable in this relationship. Instead, loss of physical function, such that one cannot take care of basic needs (e.g., dressing, bathing) or must give up valued activities, is the significant vulnerability factor (Zeiss et al. 1996).

Anxiety disorders in older adults occur more often than depression, with estimates of approximately 5.5 percent prevalence (e.g., Beck and Stanley 1997). However, in comparing younger and older adults, the rate of anxiety is lower in older adults than in any other age group. Older women are more likely to be diagnosed with anxiety than older men. Although more prevalent than depression, anxiety disorders have been less studied in older adults. Panic disorders, phobias, generalized anxiety disorder, and post-traumatic stress disorder in older veterans have received the greatest attention.

Dementia is characterized by loss of cognitive function sufficient to impair performance of daily activities. Most dementias are due to irreversible changes in the brain; the most common are Alzheimer’s disease and vascular dementias. Reversible causes occur in 10–20 percent of dementia patients, as a response to a medication or physical illness, such as thyroid dysfunction, vitamin B12 deficiency, or a treatable brain lesion. Usually, when reversible causes of dementia are treated, good recovery ensues with return to prior level of cognitive functioning. Since most forms of dementia are progressive, it is important to identify the disease early. However, assessment of dementia in older adults is difficult; in particular, patients differentiating depression and dementing illness can be difficult to differentiate (Kaszniak and Scogin 1995). Alzheimer’s disease affects not only the person with the disease, but also the family (Thompson and Gallagher-Thompson 1996). Family members experience a range of emotions that can include guilt, anger, and depression. There are also positive components of providing care for a person with Alzheimer’s, and many family members report caregiving as a rewarding experience.

1.6 Problems In Daily Living

Clinical geropsychologists need to be aware of many problems that can interfere with the ability to carry out normal daily activities for older adults. These include deficits in social and daily living skills, decision-making capacity, and elder abuse and neglect. Of these issues, elder abuse is one of the most difficult to handle; law in all states mandates reporting of elder abuse; the primary goal of reporting is to stop the abuse.

1.7 Sociocultural And Socioeconomic Factors

A variety of sociocultural issues are important in understanding the experience of aging, including losses from a variety of sources (deaths, end of employment, limitations in functioning, financial problems, environmental restrictions); cross-cultural and minority aging issues (e.g., interacting with older minorities to convey respect); the role of religion and spirituality; and the roles of intergenerational acquaintances, lifelong friendships, intimate relationships, and other social relations.

1.8 Special Issues In The Assessment Of Older Adults

Clinical geropsychologists are asked to evaluate older adults with regard to presence or absence of psychopathology, cognitive capacity, competency to make decisions, substance abuse, etc. As with younger adults, the techniques used in psychological assessments include clinical interviewing, life history record and data review, cognitive and neuropsychological evaluations, behavioral assessments, and situational observations; however, with older adults, psychologists need to use different norms for tests and to include cognitive testing more frequently. With patients who exhibit disruptive and/or potentially harmful behavior (e.g., wandering, shouting, assaultiveness), behavioral assessment is helpful in determining what type of techniques would be useful for working with the patient (see Lichtenberg 1999 for thorough overview).

1.9 Treatment Of Older Adults

Psychotherapy with older adults is as effective as therapy with younger adults. Most research on psychotherapy with older adults has used cognitive behavioral approaches, and these have been shown to be effective for a wide variety of problems (Scogin and McElreath 1994). There also is a small amount of literature supporting the use of other approaches, such as Interpersonal Therapy and Brief Time-limited Psychodynamic Therapy, especially with depression in older adults (see Zarit and Knight 1996).

There are few major content differences in therapy with older compared to younger adults. Older adults have more health problems resulting in functional impairment, and psychological status is often related to their functional status. In addition, older adults may face obstacles in terms of resources for supporting adequate quality of life, such as limited financial resources or transportation, or the experience of loss of friends or family. The largest content difference is the need to deal more frequently with older adults with therapy issues related to death and dying. Many older adults accept death as part of the life course and engage in active adaptations to death, for example, by making wills, leaving instructions, negotiating interpersonal conflicts, and reintegrating life experiences in a meaningful way, but others have greater emotional difficulty in facing death or dealing with losses of loved ones. Clinical geropsychologists must be sensitive to factors that influence the experience of death and dying, including gender, class, economic variables, and cultural considerations. Recent studies have shown that bereavement practices, once highly structured and culturally determined, are becoming diverse; as a consequence, what practices will be therapeutic is becoming more individualized rather than shared within a common culture (Riley 1992).

With regard to therapy process, chronological age is not a good marker for what adaptation of therapeutic strategies originally developed with younger adults may be needed. Therapy adaptations to enhance utility with older adults might be helpful or even necessary, but assessment of each client determines which adaptations are appropriate (see Zarit and Knight 1996 for a thorough summary of suggestions regarding therapy adaptations). Primary areas of adaptation include changes to compensate for memory and information processing deficits with older adults. As a result of cognitive changes, the pace of therapy may be slower than with younger adults. More repetition of material may be necessary, and processing of new ideas may be slower. Memory aids, such as audiotapes of therapy sessions or written summaries of each session, may be helpful. It may help to present material in multiple ways, both because of potential sensory loss and because repetitions provide multiple routes to memory storage. A key phrase for therapists working with older adults is ‘Say it, Show it, Do it’: state it clearly, write it down, and help the client use the idea in a specific way.

On the positive side, some changes in therapy process reflect relative strengths of older adults. One such strength can be thought of as wisdom (Baltes and Staudinger 1993), which is an age-related, but not inevitable, consequence of life experience. Older adults have faced many difficult life experiences, and most can abstract helpful information from those experiences and describe personal skills that have helped them handle adversity. Showing respect for the client’s accumulated experience can enhance therapy.

1.10 Prevention And Crisis Intervention Services With Older Adults

Outreach, referral, and early intervention are important for making assessment and therapy available to older adults. The organization of many health care systems presents significant obstacles to good care for older adults who may need care provided in their homes, need short, easy drives to reach services, need care for the patient and the caregiving system, etc. In addition, providing health promotion resources to older adults is useful yet often neglected. For example, exercise is effective in improving physical and mental health for older adults, but may not be recommended or supported by health care providers to the extent it is with younger adults.

1.11 Consultation

Since most health care providers are not well trained in providing services to older adults, yet the demand is great and growing, clinical geropsychologists frequently need to provide consultation. Consultation to other professionals is a major component of this work and includes providing specialized information to health care institutions, agencies, and community organizations; providing staff training; and consulting on program development. In addition, consultation to families, lay caregivers, and self-help and support groups is needed.

1.12 Interface With Other Disciplines

Since typical problems older adults face are multimodal, a comprehensive interprofessional approach to assessment and treatment that encompasses diverse health care providers (e.g., geriatricians, nurses, social workers) as well as psychologists is usually needed. The biopsychosocial model combines clinical and scientific approaches to treatment by defining problems in relation to the interactions among biological, social, and psychological systems. This model captures the complexity inherent in addressing the problems of older adults and highlights the need for an interprofessional approach (Zeiss and Steffen 1998).

1.13 Special Ethical Issues In Providing Services To Older Adults

Special ethical issues with older adults include obtaining informed consent for treatment with cognitively impaired elders, balancing patient autonomy and self-determination with apparent needs for care, balancing competing interests between older adults and family members, role conflicts in nursing homes, and confidentiality issues in working with families and teams.

2. Summary And Future Directions

Older adults are a heterogeneous population in terms of values, motives, social and psychological status, and behavior, as well as a quickly growing one. The need for clinical psychologists to be more informed about work with this diverse population of older adults have been summarized in the definition of proficiency in clinical geropsychology. That definition emphasizes broad-based knowledge of aging and adaptations of assessment and treatment for older adults. It also emphasizes the need for psychologists to work as part of interprofessional teams to meet the broad biological, social, and psychological needs of older adults.

However, as helpful as this summary is, much of what we currently know is based on research with the current cohort of older adults, particularly those who are Caucasian Americans. That research does not fully represent the heterogeneity within older adults now and will be less representative of future generations of older adults. In particular, there is considerable speculation that the large number of children born after World War II (now nearing older adult status) may age differently; two competing issues have been raised. First, it is often suggested that this cohort of elders may be more open to psychological interventions, escalating needs for research on assessment and therapy with older adults and for enhanced training of all clinical psychologists regarding work with older adults. On the other hand, coming generations of older adults may be healthier and more functional (Waidmann and Liu 2000), reducing depression and other psychological sequelae of disability, thus reducing the need for psychological interventions. The increasing proportion of minority elders also will create challenges; as current generations of minority Americans age they will carry with them salient features such as a continuing imbalanced sex ratio, segregated distribution, and proportion in poverty. Clearly, researchers and clinicians in clinical geropsychology need to be guided by research to date but open to dramatic shifts in the field.

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