Manual Psicoger Spar

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Clinical Manual ofGeriatric Psychiatry


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Washington, DCLondon, England

Clinical Manual ofGeriatric Psychiatry

James E. Spar, M.D.Professor of Clinical Psychiatry

Department of Psychiatry & Biobehavioral Sciences

Geffen School of Medicine at UCLA

Los Angeles, California

Asenath La Rue, Ph.D.Senior Scientist

Wisconsin Alzheimers Institute

University of Wisconsin School of Medicine and Public HealthMadison, Wisconsin


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Note: The authors have worked to ensure that all information in this book is accurate

at the time of publication and consistent with general psychiatric and medical standards,and that information concerning drug dosages, schedules, and routes of administrationis accurate at the time of publication and consistent with standards set by the U.S.Food and Drug Administration and the general medical community. As medicalresearch and practice continue to advance, however, therapeutic standards may change.Moreover, specific situations may require a specific therapeutic response not includedin this book. For these reasons and because human and mechanical errors sometimesoccur, we recommend that readers follow the advice of physicians directly involved intheir care or the care of a member of their family.

Books published by American Psychiatric Publishing, Inc., represent the views andopinions of the individual authors and do not necessarily represent the policies andopinions of APPI or the American Psychiatric Association.

Copyright 2006 American Psychiatric Publishing, Inc.ALL RIGHTS RESERVED

Manufactured in the United States of America on acid-free paper10 09 08 07 06 5 4 3 2 1

First EditionTypeset in Adobes Formata and AGaramond.

American Psychiatric Publishing, Inc.1000 Wilson BoulevardArlington, VA 22209-3901www.appi.org

Library of Congress Cataloging-in-Publication Data

Spar, James E.

Clinical manual of geriatric psychiatry / James E. Spar, Asenath La Rue.1st ed.p. ; cm.

Includes bibliographical references and index.ISBN 1-58562-195-1 (pbk. : alk. paper)

1. Geriatric psychiatryHandbooks, manuals, etc. 2. Older peopleMentalhealthHandbooks, manuals, etc. 3. Older peoplePsychologyHandbooks,manuals, etc.

[DNLM: 1. Aged. 2. Mental Disordersdiagnosis. 3. Mental Disorderstherapy.

4. Age Factors. 5. Agingpsychology. WT 150 S736c 2006] I. La Rue, Asenath,1948 II. Title.

RC451.4.A5S63 2006618.97'689dc22

2006005228

British Library Cataloguing in Publication DataA CIP record is available from the British Library.
http://www.appi.org/http://www.appi.org/


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Contents1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

An Aging World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Health and Functioning of Older Adults. . . . . . . . . . . . . .3

Mental Disorders in Later Life . . . . . . . . . . . . . . . . . . . . . .6

Barriers to Geriatric Mental Health Care. . . . . . . . . . . . . .8

Diversity in Patterns of Health and Aging. . . . . . . . . . . .12

Working Effectively With Older Adults. . . . . . . . . . . . . . .15

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

2 Normal Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Conceptual Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Cognitive Abilities in Later Life: A Processing

Resource Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Personality and Emotional Changes . . . . . . . . . . . . . . . .38

Social Context of Aging . . . . . . . . . . . . . . . . . . . . . . . . . .43

Biological Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Aging and the Clinical Process. . . . . . . . . . . . . . . . . . . . .50

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

3 Mood DisordersDiagnosis . . . . . . . . . . . . . . . . 67Normal Grief (Bereavement) . . . . . . . . . . . . . . . . . . . .68

Complicated Grief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

Depression Due to a General Medical Condition . . . . .70

Substance-Induced Mood Disorder . . . . . . . . . . . . . . . .76

Major Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80

Dysthymic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Minor Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Depressive Personality Disorder . . . . . . . . . . . . . . . . . . .95

Laboratory Evaluation of Depression . . . . . . . . . . . . . . .95

Psychological Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Symptom Rating Scales and Depression Screening . . .97

Assessing Suicidality in the Elderly . . . . . . . . . . . . . . . .105

Theories of Depression . . . . . . . . . . . . . . . . . . . . . . . . .107


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Hypomania and Mania . . . . . . . . . . . . . . . . . . . . . . . . . .110

Mixed Mood Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . .117References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117

4 Mood DisordersTreatment . . . . . . . . . . . . . . .127Psychotherapy for Geriatric Depression . . . . . . . . . . . .127

New Directions in Psychotherapy Research. . . . . . . . .130

Combined Psychotherapy and Pharmacotherapy . . . .132

Psychopharmacotherapy for Geriatric Depression . . .132Psychopharmacotherapy for Psychotic Depression. . .156

Psychopharmacotherapy for Bipolar Depression. . . . .157

Electroconvulsive Therapy . . . . . . . . . . . . . . . . . . . . . . .157

Experimental Therapies . . . . . . . . . . . . . . . . . . . . . . . . .159

Complementary and Alternative Approaches . . . . . . .161

Hypomania and Mania . . . . . . . . . . . . . . . . . . . . . . . . . .162

Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166

5 Dementia andAlzheimers Disease. . . . . . . . . . . . . . . . . . . . . .173

Identifying the Dementia Syndrome. . . . . . . . . . . . . . .173

Common Etiologies of Dementia . . . . . . . . . . . . . . . . .186

Alzheimers Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .192References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221Resources for Dementia Caregivers . . . . . . . . . . . . . . .228

6 Other Dementias and Delirium . . . . . . . . . . . . 229Frontotemporal Dementia . . . . . . . . . . . . . . . . . . . . . . .229

Dementia With Lewy Bodies . . . . . . . . . . . . . . . . . . . . .235

Vascular Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241Mixed Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

Dementia Due to General Medical Conditions . . . . . .249

Substance-Induced Persisting Dementia . . . . . . . . . . .254

Reversible Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . .255

Delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265


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7 Anxiety Disorders andLate-Onset Psychosis. . . . . . . . . . . . . . . . . . . . .273Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273

Late-Onset Psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . .293

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .306

8 Other Common Mental Disordersof the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313

Alcohol Abuse and Dependency . . . . . . . . . . . . . . . . . .320

Other Psychoactive Substance Abuse

and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326

Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329

Psychiatric Illness Related to a General

Medical Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . .334

Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337Influence of Aging on Disorders of Early Onset . . . . . .339

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341

9 Competency and Related Forensic Issues. . . . 347Decisional Competency . . . . . . . . . . . . . . . . . . . . . . . . .348

Undue Influence: The Question of Voluntariness . . . .358

Competency to Care for Oneself andManage Ones Finances . . . . . . . . . . . . . . . . . . . . . . . .360

Expert Consultation and Testimony

on Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .366

Competency to Drive . . . . . . . . . . . . . . . . . . . . . . . . . . .367

Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .371

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373

Appendix: Clinical AssessmentInstruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . .379

Geriatric Depression Scale . . . . . . . . . . . . . . . . . . . . . . .380

Six-Item Orientation-Memory-Concentration Test. . . .382

Cognistat profile: Example . . . . . . . . . . . . . . . . . . . . . . .383


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Instrumental Activities of Daily Living (IADL) Scale . . .384

Revised Memory and Behavior ProblemsChecklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386

Items Rated on the Neuropsychiatric Inventory. . . . . .388

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389


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1

1Introduction

An Aging World

For the first time in history, most people in societies such as our own can planon growing old. Life expectancy from birth has increased dramatically in the

United States, from about 47 years in 1900 to 77.3 years in 2002 (Federal In-teragency Forum on Aging-Related Statistics 2004). Even those people whoare currently old can expect to live for many years. For men at age 65, aver-age life expectancy is more than 16 years, and for women at age 65, it is almost20 years; at age 85, men can expect to live 6 more years and women 7 years(Federal Interagency Forum on Aging-Related Statistics 2004).

More than 20% of the current U.S. population are older than age 55, and

more than 12% are 65 or older (Federal Interagency Forum on Aging-RelatedStatistics 2004).The elderly population is the only age segment of the popu-lation that is expected to grow substantially in the next quarter century, sothat by the year 2030, one in three Americans will be age 55 or older, and onein five will be at least age 65. Very old people (85 years and older) constituteone of the fastest-growing subgroups of the elderly population (Figure 11).In 1900, a little more than 100,000 people were age 85 years or older in the

United States, compared with an estimated 4.2 million in 2000 (NationalCenter for Health Statistics 2004).By 2050, there will be 19 million to 24million people in this 85 and older age group, or nearly 5% of the total pop-ulation. In 2003, more than 50,000 U.S. residents were 100 years or older, anincrease of 36% since 1990 (Administration on Aging 2004).


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2 Clinical Manual of Geriatric Psychiatry

Worldwide, average life expectancy has increased to about 65 years (Cohen2003), and by 2050, the number of people age 65 years and older is projectedat 2.5 billion worldwide (20% of the total population) (Olshansky et al. 1993).Substantial increases in elderly populations are projected in the next quartercentury for North America, Europe, Asia, Latin America, and the Caribbean,with smaller increases expected for areas such as sub-Saharan Africa, where both

fertility and mortality rates are high. China alone is expected to have 270 mil-lion persons age 65 and oldernearly the total current population of theUnited Statesby the middle of this century. As one demographer recentlypointed out, the twentieth century may well be the last in which younger peopleoutnumbered older ones (Cohen 2003).By 2050, there will be more than threeadults age 60 years or older for every child age 4 years or younger.

Figure 11. Populations of older adults in the United States (in millions).Source. Adapted from Federal Interagency Forum on Aging-Related Statis-tics 2004.

65 and older

85 and older

Projected

205020201900 1930 1960 19900

20

40

60

80

100

Population

(millions)


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Introduction 3

Health and Functioning of Older Adults

Most people age 65 and older have at least one chronic medical illness, andmany have multiple conditions. The most common illnesses affecting elderlypeople in the United States are arthritis, hypertension, and heart conditions(Figure 12). Sensory impairments are also prevalent. Of 65- to 74-year-olds,30% report problems seeing and 18% report problems hearing; these rates areapproximately twice as high for persons age 85 and older (Federal InteragencyForum on Aging-Related Statistics 2004).Each of these conditions can limitindependent function and detract from quality of life. Being overweight orobese has increased dramatically among older Americans in recent years. Thepercentage of 65- to 74-year-olds who were overweight rose from 57% to73% between 1976 and 2002, and the obesity rate increased from 18% to36% (Federal Interagency Forum on Aging-Related Statistics 2004).By con-trast, rates of cigarette smoking declined by 2002 to 10% among older menand have remained steady in recent years at about 9% among older women.

Heart disease, cancer, and stroke account for two of every three deaths amongthe elderly and also account for many doctor visits and days of hospitalization.Death rates due to heart disease and stroke decreased by approximately one-thirdfrom 1981 through 2001, whereas death rates due to diabetes and chronic lowerrespiratory diseases increased by 43% and 62%, respectively (Federal InteragencyForum on Aging-Related Statistics 2004).Alzheimers disease ranked sixth, afterheart disease, cancer, cerebrovascular diseases, respiratory diseases, and influenzaor pneumonia, among causes of death for Americans age 65 years and older in2002 (National Center for Health Statistics 2004).

In 2002, people age 65 and older were hospitalized more than three timesas often as those ages 4564, and they remained in the hospital about a daylonger on average than did middle-aged adults (Administration on Aging2004).Older adults visited their physicians six to seven times per year on av-erage, compared with three to four times for 45- to 64-year-olds.

In 1999, about 20% of older adults were chronically disabled as a resultof health problems; about 3% had limitations in only higher-order activitiesof daily living (e.g., financial management, transportation, medication sched-ules), 6% had impairment in one or two basic activities of daily living (e.g.,eating, bathing, toileting), another 6% were impaired in three to six basic ac-tivities, and slightly fewer than 5% were institutionalized (Federal Inter-


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agency Forum on Aging-Related Statistics 2004).Of disabled older peopleliving in the community, 66% received informal care only, generally from rel-atives; 26% received a combination of formal and informal services; and 9%had formal care only (Federal Interagency Forum on Aging-Related Statistics2004).The proportion receiving paid care has increased since the early 1980s,reflecting improved financial resources of older persons as well as liberaliza-tion in coverage rules under Medicare and Medicaid. Figure 13 shows agetrends in independent and assisted living within the United States.

Those with chronic needs that cannot be met at home generally receive care

in nursing homes. Although fewer than 5% of elderly Americans are in nursinghomes at a given time, the proportion of older persons requiring such care in-creases quite sharply with age (see Figure 13). Among persons who reachedtheir 60th birthday in 1990, more than one-half of the women and one-thirdof the men are expected to enter a nursing home at some point in the future.However, older black Americans and elders from other minority groups use

Figure 12. Percentage of people age 65 and older with selected chronicconditions, 20012002.Source. Adapted from Federal Interagency Forum on Aging-Related Statis-tics 2004.

0

20

40

60

80

100

Men Women

Heartdisease

Hyper-tension

Stroke Emphy-sema

Asthma Chronicbronchitis

Cancer Diabetes Arthriticsymptoms

American

sage65(%)


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Introduction 5

paid in-home services and nursing home care less frequently than do white

Americans (National Center for Health Statistics 2004).Between 1985 and1999, the percentage of older adults residing in nursing homes in the UnitedStates declined slightly, from 5.4% to 4.3%, but the total number of older nurs-ing home residents increased from 1.3 million to 1.5 million because of growthin the older population (Federal Interagency Forum on Aging-Related Statistics2004). Three-fourths of current nursing home residents are women.

Health care costs for older Americans increased substantially from 1992

through 2001, after adjustment for inflation. During this time span, the pro-portion of health care dollars spent on acute hospital care decreased, while theproportion spent on prescription drugs increased. The average cost of provid-ing health care for persons age 65 or older is currently three to five timesgreater than health care costs for younger persons (Centers for Disease Con-trol and Prevention 2004). Long-term-care costs, including nursing homeand home health expenditures, doubled between 1990 and 2001, a trend

Figure 13. Percentage of Medicare enrollees age 65 and older, by type ofresidence, 2003.Source. Adapted from Federal Interagency Forum on Aging-Related Statis-tics 2004.

0

20

40

60

80

100

65 6574 7584 85

Traditionalcommunity

Community housingwith services

Long-term-care facility

5 5

2

1

1 319

74

9298

93

7

Age (years)

Medicareenrollees(%)


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shared by other developed nations. In 2001, the average annual cost for el-

derly residents of long-term-care facilities in the United States was $46,810,compared with $8,466 for community residents of comparable age (FederalInteragency Forum on Aging-Related Statistics 2004). Total Medicare spend-ing increased from $33.9 billion in 1980 to $252.2 billion in 2002 and is pro-jected to grow to twice that amount by 2012 (Centers for Disease Controland Prevention 2004).

These trends present a significant challenge to the health care community.

The need to learn about aging and older people extends throughout the med-ical and mental health professions. Creative approaches are required to stemrising costs while maintaining quality assessment and intervention. Allianceswith families and other natural supports must be formed to ensure continuityof care, and the strengths of older patients themselves must be marshaled tocope with illness and to interact effectively within the health care system.

Mental Disorders in Later LifeOlder people with mental disorders constitute a significant subgroup of theelderly population. The multisite Epidemiologic Catchment Area (ECA)Study conducted in the 1980s (Robins and Regier 1991)found that nearly20% of Americans age 55 and older had diagnosable mental disorders, in-cluding dementia (U.S. Public Health Service 1999).The ECA findings are

believed by many experts in the field to be underestimates because of meth-odological limitations in the ECA assessment procedures. A 1999 consensusconference on geriatric mental health estimated the prevalence of psychiatricdisorders in community-residing older adults at 25% or more (Jeste et al.1999).Rates of mental disorder are much higher among elderly patients seenin primary care or hospitalized for medical conditions, 30%50% of whomhave psychiatric conditions (Borson and Untzer 2000;Rapp et al. 1988);

and in long-term-care settings, 68%94% of residents have been found tohave mental disorders (Hybels and Blazer 2003).Table 11 compares rates forseveral different types of mental disorders in the ECA community-based sur-vey (1-month prevalence data) with a survey of hospitalized geriatric patientsconducted at about the same time. Overall, it is reasonable to estimate that15%25% of Americans who are currently age 65 or older have significantmental health problems.


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Introduction 7

Older patients experience the same broad spectrum of mental disorders as

do younger adults. However, certain conditions are particularly notable in laterlife because of either increased prevalence or high morbidity (see Table 11).

The elderly are at much greater risk for cognitive impairment than areyounger adults. In the community, at least 5% of people age 65 years or olderhave prominent cognitive deficits, compared with fewer than 1% of people ages1864 (Regier et al. 1988).A larger proportion of older people have mild cog-nitive problems, with estimates varying widely depending on the procedures

used to assess impairment (see Chapter 2, Normal Aging). The numbers inTable 11 may underestimate the extent of problems related to cognitive defi-cits, especially in the oldest age ranges. Recent data from the national Healthand Retirement Study showed that among Americans age 85 and older residingin the community, one-third had moderate to severe memory impairment (Ad-ministration on Aging 2004), and a widely cited epidemiological survey in theEast Boston area reported a prevalence of 47% for Alzheimers disease alone

among community residents age 85 and older (Evans et al. 1989).Cognitive deficits in older patients have many different possible causes,and in many cases, treatment of underlying problems can substantially allevi-ate cognitive symptoms or slow the course of further decline (see Chapter 5,Dementia and Alzheimers Disease, and Chapter 6, Other Dementias andDelirium). Even for individuals with dementia of the Alzheimers type, gainsin functional ability can be obtained by treating coexisting medical or psychi-

atric illnesses. These small gains can make a great difference to family mem-bers caring for these patients, as can support, psychotherapy, and respiteprovided for caregivers.

Depression is an equally important condition in older adults. In the com-munity, the percentage of older people meeting strict diagnostic criteria formajor depression is generally estimated at 5% or less (U.S. Public Health Ser-vice 1999). However, traditional diagnostic criteria may not do justice to the

prevalence of depressive symptoms among older people. Serious depressivesymptoms were found in 8%20% of elderly community residents and in upto 37% of the elderly in primary care settings (U.S. Public Health Service1999).In acute-care hospitals, as many as 25% of older patients have diag-nosable mood disorders (e.g., Rapp et al. 1988),and nearly 50% of the ad-missions of older adults to psychiatric hospitals are for depressive conditions.The presence of comorbid depression or anxiety greatly increases health care


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costs for patients in primary care (Simon et al. 1995), and over time, depres-

sion is associated with decrements in function and well-being that are similarto, or greater than, those associated with chronic medical disease (Hays et al.1995).Geriatric depression can be treated effectively with standard therapiesin 60%80% of cases (U.S. Public Health Service 1999),but it is unlikely toresolve spontaneously. Depression, anxiety, and alcohol and drug abuse in theelderly today are only about one-quarter to one-third as common as amongmiddle-aged persons, and as the 55 million baby boomers grow old, their

mental health needs may prompt a crisis in geriatric care (Jeste et al. 1999).Many older people without major mental disorders experience adjust-ment reactions to personal stresses, bereavement, pain syndromes, and sleepdisturbance. Education and interventions directed at these problems may pre-vent more serious psychiatric or medical problems from developing. The im-portance of increasing prevention efforts for older adults as well as other agegroups was underscored in the U.S. surgeon generals report on mental health

(U.S. Public Health Service 1999).For psychiatrists, therefore, it is important not only to identify and treatspecific psychiatric disorders but also to provide education, support, and pre-ventive interventions to strengthen older people and their families in manag-ing common stresses of aging.

Barriers to Geriatric Mental Health Care

Improvements have been made since the early 1990s in the detection andtreatment of mental disorders in older adults in the United States. In an anal-ysis of national Medicare fee-for-service data, for example, rates of diagnoseddepression in older adults increased from 2.8% in 1992 to 5.8% in 1998, andtwo-thirds of those diagnosed received treatment of some type (Crystal et al.2003).Similarly, since passage of the Omnibus Budget Reconciliation Act in

1987, efforts have been made, with varying degrees of success, to recognize andtreat mental disorders in patients in skilled nursing facilities. The number ofeffective antidepressant medications has increased (Chapter 4, Mood Disor-dersTreatment), and medications to slow the course of common progres-sive dementias have been introduced (Chapter 5, Dementia and AlzheimersDisease, and Chapter 6, Other Dementias and Delirium). The usefulnessof psychotherapeutic interventions for common mental disorders of older


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Introduction 9

adults has been more thoroughly confirmed (Chapters 4 through 8, MoodDisordersTreatment, Dementia and Alzheimers Disease, Other De-mentias and Delirium, Anxiety Disorders and Late-Onset Psychosis, andOther Common Mental Disorders of the Elderly, respectively), as have thecomplex relationships between mental disorders and medical illness.

Despite these improvements, significant inequities remain in identifica-tion and treatment of mental health conditions in older people and in acces-sibility and use of geriatric mental health services (Aren and Untzer 2003;Charney et al. 2003;Moak and Borson 2000).Adults older than 75, minor-ity group members, and persons with Medicare only were less likely thanyounger, white, and better-insured patients to have received treatment fordepression in recent years (Crystal et al. 2003),and even the most recentstudies continue to show that most cases of cognitive impairment withoutobvious dementia go undetected and untreated in primary care (Chodosh etal. 2004;Ganguli et al. 2004).Less common or less widely publicized con-ditions are even more likely to remain unrecognized and inadequatelytreated. In nursing homes, psychiatric services are generally restricted to aconsultative, as-requested mode instead of being a consistent and integratedpart of care management teams, and in the burgeoning numbers of assisted-

Table 11. Mental disorders among older adults

Distribution of psychiatric diagnoses (%)

Category of illness Community residentsaMedical-surgical

inpatientsb

Cognitive impairment 4.9 30.2

Affective disorders 2.5 18.5

Anxiety disorders 5.5 5.2

Alcohol abuse ordependence 0.9 2.6

Schizophrenic disorders 0.1 0

Somatization 0.1 0

Personality disorder 0 8.3

Other psychiatric disorder 0 7.9

aAdapted from Regier et al. 1988.bAdapted from Rapp et al. 1988.


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living and community-based programs for senior care, mental health services

are patchy and largely unregulated (Moak and Borson 2000).Contemporary older Americans report less past use of mental health ser-

vices than do younger adults, and older Americans are less likely to express aneed for such services (Klap et al. 2003;Wetherell et al. 2004).Older adultsmost often turn to primary care providers for help with mental health problems(Kaplan et al. 1999), and typically, only one-half or fewer follow through withreferrals to specialty mental health providers. In a recent multisite randomized

trial, elderly primary care patients who screened positive for depression, anxiety,or increased risk of alcohol use problems were offered collaborative mentalhealth services within primary care or enhanced referral assistance (e.g., sched-uling, transportation, and payment assistance to outside mental health special-ists) (Bartels et al. 2004).A significantly higher percentage of the patientsfollowed through on pursuing mental health treatment when it was availablewithin primary care (71% vs. 49%), and they completed more mental health

visits overall, than did those referred to mental health clinics or specialists, evenwith enhanced assistance aimed at increasing the odds of compliance with thereferral. As the baby boom generation edges into the geriatric age range, thestiff upper lip approach to managing emotional distress (Wetherell et al.2004)may change, but the desire for proximal, integrated medical and mentalhealth services is likely to continue. Without more effective collaborative care,underrecognition of mental health problems, especially among older patients

(Young et al. 2001), is likely to continue for several reasons:

Multiple medical illnesses in elderly patients may divert physicians attentionaway from psychiatric signs and symptoms, especially within the time-pres-sured context of the standard brief office visit.

Depression, anxiety, or memory problems may be viewed as normal forolder people with serious medical illness.

Physicians with neither psychiatric nor geriatric training may have difficultydistinguishing normal aging changes from signs of mental disorder or maybe reluctant to open the can of worms that treatment of emotional or cog-nitive problems may entail.

A probability survey of primary care providers found that only 6% of gen-eral internal medicine physicians and 22% of family practice physicians used


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Introduction 11

questionnaires or other structured procedures to screen for depression in their

older patients, relying instead on very brief informal interviews (Kaplan et al.1999).Primary care physicians report that the subtlety of mild dementiamakes it difficult to recognize during brief interviews, but many physiciansremain reluctant to use formal cognitive screening tests (Boise et al. 1999);many also believe that in the absence of effective treatment, there is little pur-pose to diagnosing mild dementia, although this attitude may delay arrange-ments for community support services and increase family strain (see Chapter

5, Dementia and Alzheimers Disease).Among psychiatrists, attitudes about aging and age-related conditionsand limited training in geriatric psychiatry may further restrict the availabilityand quality of mental health care for older patients. Many psychiatrists andother mental health professionals find it difficult to work with elderly pa-tients. Understandably, they may prefer to work with patients who have lessdaunting problems with physical illness and personal loss, who remind them

less of their own mortality, and who are less likely to die in the course of treat-ment. Nonetheless, recent research has not found mental health professionalsto be strongly or pervasively negative in their attitudes about older patients.Instead, age bias seems to take more specific forms (Gatz and Pearson 1988).American psychiatrists and other mental health professionals tend to referolder patients less often for psychotherapy than comparably ill younger pa-tients, and some of these professionals, in an attempt to avoid discrimination

against the elderly, may exaggerate the competencies and excuse the deficitsof elderly patients. Fallacy for good reasons is a phrase coined to refer to thecommon situation in which a provider, as well as the patient and family mem-bers, attributes the depression or anxiety experienced by the older patient tomedical illness, multiple losses, or financial difficulties that many older per-sons face, especially the very old (Cole et al. 1997).

Inadequate insurance coverage for patients and limited reimbursement

for providers are ongoing barriers to geriatric mental health care. Because pre-scription drugs have not been covered under Medicare until very recently, el-ders who could not afford a coinsurance policy with drug benefits wereunable to afford psychiatric medications. The 50% copayment rule for psy-chotherapy services under most insurance policies makes the decision to en-gage in therapy costly to the patient, and allowable fees are often inadequate(e.g., under Medicare, the psychotherapy fees allowed for an experienced psy-


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chiatrist are half or less of the typical fee expected for this service). The elderly,

who generally have many health care needs, often have trouble coordinatingtheir own care, but there is usually no reimbursement for mental health pro-viders to help with coordination.

The need for psychiatrists who are capable and willing to work with el-derly patients, both in primary care and in specialty roles, is clear. Effectivemodels for collaborative medical and mental health services recently havebeen developed for primary care (see Chapter 4, Mood DisordersTreat-

ment), but this approach needs to be extended beyond clinical research, andadditional models need to be developed for geropsychiatric services withincommunity mental health settings and the full spectrum of long-term-careservices (Moak and Borson 2000).Older adults with medical comorbidity,the oldest old, and those with significant chronic mental illness present par-ticular challenges to existing service models (Borson et al. 2001).

Diversity in Patterns of Health and AgingIn 2003, persons of minority descent, including Hispanic whites, accountedfor 17.6% of the U.S. population age 65 and older, but by 2050, this percent-age is projected to rise to 36%. Hispanic and Asian American groups as awhole are the most rapidly growing minority populations, and these trendsare projected to continue (Figure 14).

Methodological difficulties encountered in the processes of sampling, de-signing valid interview protocols, achieving subject cooperation, and control-ling interviewer and subject bias have hampered attempts to generalize aboutthe health and other characteristics of black, Hispanic, American Indian, andAsian populations in the United States. However, in key areas such as life ex-pectancy, prevalence of chronic health conditions, residential patterns, andeducation, significant differences have been documented across groups. In the

United States in 2001, average life expectancy from birth was 5.5 years longerfor white persons than for black Americans (Federal Interagency Forum onAging-Related Statistics 2004).At age 65, however, the life expectancy gapnarrowed to about 2 years, and by age 85, life expectancy was slightly longerfor older black persons compared with white persons. In 20002001, amongpeople age 65 and older, hypertension and diabetes were more commonamong black than among non-Hispanic white persons; older Hispanics were


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Introduction 13

comparable to non-Hispanic white Americans in rates of hypertension butwere more likely to have diabetes. By contrast, older white people were morelikely to have some form of cancer than were older Hispanic or black people(National Center for Health Statistics 2004).Black and Hispanic elders areless well educated than non-Hispanic white and Asian elders (see Figure 21in Chapter 2, Normal Aging), and older black and non-Hispanic white per-sons are more likely to find themselves living alone in old age than are theirHispanic or Asian peers (see Figure 22 in Chapter 2).

Reports of prevalence of mental disorders for minority groups must beviewed with caution because language and cultural differences can affect re-sults on tests and interviews assessing depression, dementia, and other psychi-atric disorders. However, data are emerging on the relative prevalence ofmental healthrelated problems in various groups and on availability and useof mental health services. A recent supplement (U.S. Public Health Service

Figure 14. Percentage of population age 65 and older, by race and His-panic origin.Source. Adapted from Federal Interagency Forum on Aging-Related Statis-tics 2004.

0

20

40

60

80

100

2003

2050projected

Non-Hispanicwhite alone

Black alone Asian alone All other races aloneor in combination

Hispanicof any race

Americansa

ge65(%)


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2005)toMental Health: A Report of the Surgeon General (U.S. Public Health

Service 1999)concluded that the prevalence of mental disorders within themost populous racial and ethnic minority groups in the United States (blacks,Hispanics, and Asian Americans and Pacific Islanders) is similar to that ofwhite Americans. Among older adults, however, some important differencesin prevalence of mental healthrelated conditions have been documented forracial/ethnic and gender subgroups. For example, the suicide rate is muchhigher among non-Hispanic white men than in any other elderly subgroup

(National Center for Health Statistics 2004),and rates of alcohol abuse anddependence are higher among elderly black men and women compared withelderly white and Hispanic persons (U.S. Public Health Service 1999).

The surgeon generals recent supplement underscored the pivotal role ofculture in maintaining mental health and the continuing, often striking, dis-parities in availability of and access to mental health services among Ameri-cans from minority backgrounds. Although not specific to older adults, the

recommendations for reducing barriers are as important for diverse geriatricpopulations as they are for younger groups. The recommendations includethe following:

Continuing research to establish the efficacy of evidence-based treatmentsfor racial and ethnic minorities and to better characterize how factors suchas acculturation and ethnic identity affect risk for, and protection from,

mental illness Improving access to treatment by improving geographic distribution ofservices, increasing availability of services in preferred languages, and co-ordinating care for the most vulnerable, high-need subgroups in whichracial and ethnic minorities are overrepresented (e.g., low-income orhomeless persons)

Delivering effective, evidence-based treatments that are individualized ac-

cording to age, gender, race, ethnicity, and culture Working toward equitable racial and ethnic representation among mentalhealth providers, administrators, and policy makers

Women constitute the majority of older persons in the United States, out-numbering men by a ratio of nearly 3 to 1 by age 85 and older. Importantgender differences have been reported for longevity, prevalence of specific


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Introduction 15

medical or mental conditions (e.g., heart disease, Alzheimers disease), andrates of disability. At present, the price that women pay for longer lives ap-pears to be a greater proportion of the late life span compromised by func-tional disability, limited options for home care, and an increased likelihood ofspending their last years in a nursing home. Recent research, prompted by theWomens Health Initiative, is helping to elucidate whether preventive healthcare, or more prompt and appropriate diagnosis and treatment of medicalconditions, can reduce the functional limitations now experienced dispropor-tionately by women in later years.

Working Effectively With Older Adults

Psychiatric care of older patients requires a blending of specialized knowledgewith a broadly based, flexible approach to the patient (Table 12).

In addition to mastering the content areas covered in this Clinical Man-ual, a psychiatrist treating older patients needs certain personal qualities andprofessional approaches that are important for effective work in geriatric psy-chiatry (Table 13). Although some older people can manage todays complexhealth care system, many more lack the energy, sophistication, cognitive abil-ity, or funds to negotiate a specialty-oriented system successfully. As a result,psychiatrists working with older people must be willing to play a generalistrole, combining routine medical management with psychiatric interventionsor helping with specific social or situational problems.

Table 12. Knowledge needed to work effectively with elderly

patientsNormal aging: biological, psychological, and social changes

Mental disorders predominantly observed in later life, including Alzheimers disease,related dementias, late-onset psychoses

Effects of age on other psychiatric disorders, including mood and anxiety disorders

Adjusting psychiatric treatments for aging changes: dose and schedule ofpsychoactive medications, drug-drug interactions, format and pace of

psychotherapyManaging social and physical problems of later life: bereavement, role loss, pain,sleep disturbance

Interactions of psychiatric and medical-surgical illnesses and their treatments


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The psychiatrist also must have patience and skill in explaining diagnosesand treatments and in assisting older people in medical decision making. El-derly patients often defer to physicians without truly comprehending benefits

and risks. This deference may increase efficiency of care in the short run, butit may place the older person at risk for iatrogenic illness (e.g., delirium sec-ondary to drug interactions). Finally, it is helpful to have a willingness to ex-plore ones own feelings about aging, as well as to be open to discussing olderpatients reservations about the wisdom of youth. Elderly patients may be in-clined to view younger therapists as similar to their children, and the thera-pist, in response, may experience the reactivation of unresolved conflicts with

parents or grandparents or unresolved issues related to his or her own personalaging (Meador and David 1994).

References

Administration on Aging: A Profile of Older Americans: 2004. Washington, DC, Ad-ministration on Aging, 2004. Available at: http://www.aoa.gov/prof/Statistics/profile/2004/profiles2004.asp.Accessed March 9, 2006.

Aren PA, Untzer J: Inequities in depression management in low-income, minority,and old-old adults: a matter of access to preferred treatments? J Am Geriatr Soc51:18081809, 2003

Table 13. Personal qualities and professional approaches

needed to work effectively with elderly patientsWillingness to provide broadly based, flexible management

Comfort in working closely with other health care professionals

Patience and skill in providing medical information and assisting in medical decisionmaking

Willingness to explore ones own feelings about aging

Openness to discuss patients concerns about being treated by younger professionals

Acceptance of and comfort with limited treatment goalsAbility to maintain therapeutic optimism in the context of an ultimately poor

prognosis
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Introduction 17

Bartels SJ, Coakley EH, Zubritsky C, et al: Improving access to geriatric mental health

services: a randomized trial comparing treatment engagement with integratedversus enhanced referral care for depression, anxiety, and at-risk alcohol use. AmJ Psychiatry 161:14551462, 2004

Boise L, Camicioli R, Morgan DL, et al: Diagnosing dementia: perspectives of primarycare physicians. Gerontologist 39:457464, 1999

Borson S, Untzer J: Psychiatric problems in the medically ill, in Comprehensive Text-book of Psychiatry/VII. Edited by Kaplan HI, Sadock BJ. Philadelphia, PA, Lip-pincott Williams & Wilkins, 2000, pp 30453053

Borson S, Bartels SJ, Colenda CC, et al: Geriatric mental health services research:strategic plan for an aging population. Am J Geriatr Psychiatry 9:191204, 2001

Centers for Disease Control and Prevention and Merck Institute of Aging and Health:The State of Aging and Health in America 2004. Available at: http://www.cdc.gov/aging/pdf/State_of_Aging_and_Health_in_America_2004.pdf or http://www.miahonline.org/press/content/11.22.04_SOA_Report.pdf. Accessed Au-gust 26, 2005.

Charney DS, Reynolds CF III, Lewis L, et al: Depression and bipolar support allianceconsensus statement on the unmet needs in diagnosis and treatment of mooddisorders in late life. Arch Gen Psychiatry 60:664672, 2003

Chodosh J, Petitti DB, Elliott M, et al: Physician recognition of cognitive impairment:evaluating the need for improvement. J Am Geriatr Soc 52:10511059, 2004

Cohen JE: Human population: the next half century. Science 302:11721175, 2003Cole SA, Christensen JF, Raju M, et al: Depression, in Behavioral Medicine in Primary

Care: A Practical Guide. Edited by Feldman MD, Christensen JF. Stamford, CT,

Appleton & Lange, 1997, pp 177192Crystal S, Sambamoorthi U, Walkup JT, et al: Diagnosis and treatment of depression

in the elderly Medicare population: predictors, disparities, and trends. J Am Geri-atr Soc 51:17181728, 2003

Evans DA, Funkenstein HH, Albert MS, et al: Prevalence of Alzheimers disease in acommunity population of older persons. JAMA 262:25512556, 1989

Federal Interagency Forum on Aging-Related Statistics: Older Americans 2004:Key Indicators of Well-Being. Washington, DC, U.S. Government Printing

Office, 2004. Available at: http://www.aoa.gov/prof/Statistics/profile/2004/profiles2004.asp.Accessed March 9, 2006.

Ganguli M, Rodriguez E, Mulsant B, et al: Detection and management of cognitiveimpairment in primary care: the Steel Valley Seniors Survey. J Am Geriatr Soc52:16681675, 2004

Gatz M, Pearson CG: Ageism revisited and the provision of psychological services. AmPsychol 43:184194, 1988
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Hays RD, Wells KB, Sherbourne CD, et al: Functioning and well-being outcomes of

patients with depression compared with chronic general medical illness. Arch GenPsychiatry 52:1119, 1995Hybels CF, Blazer DG: Epidemiology of late-life mental disorders. Clin Geriatr Med

19:663696, 2003Jeste DV, Alexopoulos GS, Bartels SJ, et al: Consensus statement on the upcoming

crisis in geriatric mental health: research agenda for the next two decades. ArchGen Psychiatry 56:848853, 1999

Kaplan MS, Adamek ME, Calderon A: Managing depressed and suicidal geriatric pa-

tients: differences among primary care physicians. Gerontologist 39:417425,1999

Klap R, Unroe KT, Untzer J: Caring for mental illness in the United States: a focuson older adults. Am J Geriatr Psychiatry 11:517524, 2003

Meador KB, David CD: Psychotherapy, in The American Psychiatric Press Textbookof Psychiatry, 2nd Edition. Edited by Hales RE, Yudofsky SC, Talbott JA. Wash-ington, DC, American Psychiatric Press, 1994, pp 395412

Moak G, Borson W: Mental health services in long-term care: still an unmet need. AmJ Geriatr Psychiatry 8:96100, 2000

National Center for Health Statistics: Health, United States, 2004, With Chartbookon Trends in the Health of Americans. Hyattsville, MD, National Center forHealth Statistics, 2004

Olshansky SJ, Carnes BA, Cassel CK: The aging of the human species. Sci Am 268:4652, 1993

Rapp SR, Parisi SA, Walsh DA: Psychological dysfunction and physical health among

elderly medical inpatients. J Consult Clin Psychol 56:851855, 1988Regier DA, Boyd JH, Burke JD, et al: One-month prevalence of mental disorders in

the United States. Arch Gen Psychiatry 45:977986, 1988Robins LN, Regier DA: Psychiatric Disorders in America: The Epidemiologic Catch-

ment Area Study. New York, Free Press, 1991Simon G, Ormel J, Von Korff M, et al: Health care costs associated with depressive

and anxiety disorders in primary care. Am J Psychiatry 152:352357, 1995U.S. Public Health Service: Mental Health: A Report of the Surgeon General.

Rockville, MD, Office of the Surgeon General, 1999. Available at: http://www.surgeongeneral.gov/library/mentalhealth. Accessed January 27, 2006.

U.S. Public Health Service: Mental Health: Culture, Race, and Ethnicity: A Supplementto Mental Health: A Report of the Surgeon General. Rockville, MD, Office ofthe Surgeon General, 2005. Available at: http://www.surgeongeneral.gov/library/mentalhealth.Accessed March 9, 2006.
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Introduction 19

Wetherell JL, Kaplan RM, Kallenberg G, et al: Mental health treatment preferences of

older and younger primary care patients. Int J Psychiatry Med 34:219233, 2004Young AS, Klap R, Sherbourne CD, et al: The quality of care for depressive and anxietydisorders in the United States. Arch Gen Psychiatry 58:5561, 2001


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21

2Normal Aging

Conceptual Issues

Who Is Old?

Biological and psychological aging changes usually occur gradually, over years or

decades, and as a result, there is no single age at which people in general can besaid to be old. The common practice of designating people older than 65 as oldbegan in Germany in the 1880s, when Otto von Bismarck selected 65 as the start-ing age for certain social welfare benefits. In the United States, the age at whichfull Social Security benefits can be received has now been raised to 67 years forpersons born in 1960 and later. Although this change is primarily a response tofiscal concerns, the upward shift is also indicative of the increasing vitality and

productivity of the aging population. According to a recent national survey, 63years is the average age at which Americans perceive individuals as becoming old,but there was much variation in perceptions (Abramson and Silverstein 2004).More than one-third of the sample named an age greater than 70 as the start ofold age, whereas another one-fourth cited ages less than 60 years.

Gerontologists often draw finer chronological demarcations within thegeneral group of aging persons. Comparisons may be made between theyoung-

old and the old-old(generally, those younger than and older than age 75, respec-tively) or between these groups and the oldest old(generally 85 years and older).Although these distinctions are also arbitrary, they can be useful in identifyingimportant differences in levels of functioning and can help to limit overgener-alization about characteristics of older adults. It is also important to keep in


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mind that individuals may age faster in some dimensions than others (e.g.,

being old physically but more youthful psychologically or socially).

Cross-Sectional and Longitudinal Views

The most common way to study the effects of aging is to compare a group ofolder people with a separate group of younger adults. Because generationaldifferences in education, health practices, diet, and other important factorsare confounded with age differences when young and old subjects are com-

pared, cross-sectional investigations often provide an inflated estimate of themagnitude of aging changes that will occur in individuals.Longitudinal designs also have been used to study normal aging. These

investigations track the same individuals over years, or even decades. The leasthealthy and able subjects are often the first to drop out from these samples,so longitudinal investigations may provide an overly optimistic estimate ofthe extent of decline with age.

The best picture of normative aging trends is obtained from studies inwhich multiple cohorts are assessed longitudinally or by combining the re-sults of separate cross-sectional and longitudinal studies. The Seattle Longi-tudinal Study conducted by Werner Schaie (2005)and colleagues providesone of the best examples of a multiple-cohort longitudinal aging study, out-comes of which have helped to shape understanding of cognitive processesthat remain stable or reliably decline with age. At least 25 other longitudinal

investigations of behavioral aspects of aging are ongoing at this time, and aburgeoning number of cross-sectional studies are being done.

Heterogeneity in Patterns of Aging

On many psychological and biological measures, variability is greater in old-age samples than among younger adults. A longitudinal study of 426 elderlycommunity dwellers by Christensen and associates (1999)found increases in

interindividual variability with age in memory, spatial functioning, and speedbut not in crystallized intelligence. Being female, being more depressed, beingmore ill, and having weaker muscle strength were associated with greater vari-ability, whereas having a higher level of education was associated with reducedvariability. Pronounced variability decreases the sensitivity in upper age rangesof many measures that are used to infer pathological changes and casts doubton the search for singular normative aging trends. Many different normal ag-


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Normal Aging 23

ing trajectories may exist, with varying trends for different genetic and socio-

cultural subgroups. Intraindividual variability (i.e., fluctuating performancewithin and across assessments) is also increased in old age, especially for cog-nitive and physical performance measures. Heightened variability within theindividual has been linked to an accelerated rate of cognitive decline over timeand may be a marker for neurobiological aging (MacDonald et al. 2003).

Cognitive Abilities in Later Life: A ProcessingResource Model

Cognitive changes with aging are well documented and affect a broad rangeof functions (see the subsection General Aging Trends later in this section).However, many of the differences in specific abilities can be traced to declinesin three fundamental cognitive-processing resources: the speed at which in-formation can be processed, working memory, and sensory and perceptual

skill (Park 1999).

Processing Speed

Perhaps the most predictable of all cognitive changes is the reduced speed ofinformation processing and response. Slowed execution of component per-ceptual and mental operations can affect attention, memory, and decisionmaking and can influence performance even on tasks that have no obvious

speed requirements (Salthouse 1996).

Working Memory

Working memoryrefers to short-term retention and manipulation of informa-tion held in conscious memory, a type of online cognitive processing (Bad-deley 1986). Examples include consciously recalling a telephone number longenough to write it down, mentally calculating the sale price of an item that is

reduced by 15%, and mentally traversing a route that one intends to walk ordrive. Information fades from working memory within about 2 seconds, so tokeep details alive for a longer time requires active rehearsal or continuing re-focusing of attention.

Aging is associated with a decline in working memory skills, especiallywhen active manipulation of information is required (e.g., repeating numbers


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backward as opposed to forward). Reductions in working memory, in turn,

place limits on other complex cognitive skills, including reasoning and otherexecutive processes, and learning and recall of new information.

Sensory and Perceptual Changes

Most older adults experience decrements in visual and auditory acuity andother perceptual changes. Some, but not all, of the age-related visual changescan be corrected by glasses, and although hearing aids help with detection of

low-frequency tones, they often amplify background noise. In effect, manyolder adults find it hard to hear or see well, especially with competing back-ground noise and poor lighting conditions.

Recent studies suggest a strong correlative link between sensory and per-ceptual changes and cognitive performance in old age. Younger adults testedwith degraded perception (e.g., by background noise or reduced visual con-trast) perform much like older adults on measures of learning, memory, and

language (Schneider and Pichora-Fuller 2000).The extra time and effort re-quired to process information necessitated by sensory and perceptual prob-lems tax working memory, effectively overloading the system.

The combined effects of central nervous system slowing, reduced workingmemory, and sensory and perceptual changes limit the processing resources thatolder persons can bring to bear in particular situations. These changes increasethe likelihood of processing overload in circumstances that may have once pre-

sented little challenge. In advanced old age, even basic activities such as walkingor maintaining postural control become less automatic, with the result thatolder persons must devote more conscious cognitive resources to these activities.

Neuropsychological Explanations of Cognitive AgingChanges

Neuropathological and neuroimaging studies have documented widespread

changes in the human brain with aging (Raz 2000; Victoroff 2000). There aregeneralized atrophic and white matter changes as well as region-specific vari-ations in the extent of cell loss. Within the cortex, the prefrontal lobes aredisproportionately affected by aging changes, whereas temporoparietal asso-ciation areas are less affected. Subcortical monoaminergic cell populations,which connect to the frontal lobes by a complex network of projections, arealso subject to prominent decline in aging. Data are more conflicting regard-


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Normal Aging 25

ing changes in the hippocampus and entorhinal cortex, with some studies

noting minimal cell loss with normal aging in these regions and others show-ing decremental changes. Areas in which there is relative sparing with age in-clude the globus pallidus, the paleocerebellum, the sensory cortices, and thepons (Raz 2000).

Some of the behavioral changes in aging, such as slowed information pro-cessing and response, may be related to generalized changes such as decreasedbrain volume and white matter density. Other changes appear to mirror the se-

lective pattern of differential change in prefrontal cortical structures and striataldopaminergic nuclei. Decreased working memory, problems with effortfullearning and recall, and changes in efficiency of executive functions are some ofthe findings that suggest a mild degree of frontal or subcortical brain dysfunc-tion in normal aging (Prull et al. 2000). The frontal lobe hypothesis is perhapsthe most popular neuropsychological model of normal aging at this time. How-ever, hippocampal changes also may play a role in normal aging memory. Hip-

pocampal volume, as measured by magnetic resonance imaging, correlates withmemory performance in older adults, and those with smaller hippocampal vol-umes are at greater risk for developing dementia. What remains to be resolved,however, is whether reduced hippocampal volume is truly within the normalaging spectrum or instead is a preclinical phase of dementia.

Functional neuroimaging studies have shown less regional specificity inolder adults patterns of brain activation to various cognitive tasks compared

with the regional specificity in young adults (Prull et al. 2000;Raz 2000). Oneinterpretation of this finding has been that older persons must recruit moreneural systems to perform even relatively simple mental operations. This inter-pretation coincides in a general way with the behavioral model of reduced pro-cessing resources and increased susceptibility to overload on complex tasks.

General Aging Trends

Table 21 summarizes general aging trends for intelligence and specific areasof cognitive function. In this table, mild declinerefers to changes that are generallywithin a standard deviation of the mean for young adults, whereas moderate de-clinerefers to differences on the order of one to two standard deviations below theaverage for young adults. As the table indicates, cognitive changes associated withnormal aging generally fall within the mild to moderate range, and there are someareas in which performance remains stable or improves. The differential pattern


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Table 21. Aging effects on cognitive performance

Ability Direction of aging change Comment

Intelligence

Vocabulary, fund ofknowledge Stable or increasing May decline slightly in vtasks

Perceptual-motor skills Declining Decline begins by ages 5

Attention

Attention span Stable to mild decline

Complex attention Mild decline Problems with dividingattention

Language

Communication Stable In absence of sensory im

Syntax, word knowledge Stable Varies with education

Fluency, naming Mild decline Occasional word-findin

Comprehension Stable to mild decline Some erosion in process

Discourse Variable May be more imprecise,

Memory

Short-term (immediate) Stable to mild decline Forward digit span intacinterference

Working Mild to moderate decline Reduced ability to manimemory

Secondary (recent) Moderate decline Encoding and retrieval d


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Memory(continued)

Implicit Stable to mild decline May recall incidental feaprocessed information

Remote Variable Intact for major aspects

Prospective Variable Mild to moderate declinoften outperform younmemory tasks

Visuospatial

Design copying Variable Intact for simple but no

Topographic orientation Declining Most noticeable in unfaExecutive functions

Cognitive flexibility Mild to moderate decline Slower and less accurateto another

Logical problem solving Declining Some redundancy and d

Practical reasoning Mild to moderate decline Qualitatively intact, buttasks

Speed Declining Slowing of thought and

Table 21. Aging effects on cognitive performance (continued)

Ability Direction of aging change Comment


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of abilities shown in Table 21 is less apparent among the oldest-old (e.g., 85 or

older), for whom some studies report a generalized pattern of gradual decline. An-other important qualification concerns secular trends in levels of performance. In-tellectual performance scores have been increasing over the past few decades, andthe rate of increase is higher among older, as opposed to younger, adults. For ex-ample, vocabulary scores on the commonly used Wechsler Adult IntelligenceScale (Wechsler 1997)have increased nearly 5 IQ points per decade for 65- to 74-year-olds, compared with 1.5 points for 18- to 24-year-olds (Uttl and Van Alstine

2003).Higher absolute levels of intellectual ability may benefit contemporaryolder adults in learning new information and acquiring new skills (see the subsec-tion Effect of Cognitive Change on Everyday Function later in this section).

Factors That Influence Cognitive Aging

Table 22 summarizes characteristics and experiences that influence the de-gree of cognitive change individuals show as they age. The cumulative effect

of these factors, operating over months or years, may be responsible for in-creasing variability in cognitive performance at older ages. Healthy andstimulating lifestyles, in addition to early life advantages such as adequate ed-ucation, are hypothesized to strengthen the cognitive reserve that individu-als have available to cope with neurobiological changes resulting from agingor illness (Scarmeas and Stern 2003).Increasing evidence, for example, indi-cates that physical and mental exercise, a healthy diet, and strong social sup-

ports may serve as protective factors against the development of dementia(e.g., Fratiglioni et al. 2004).

Learning and Memory

When older people complain about their cognitive abilities, they usually men-tion problems with memory. Research substantiates these complaints, but asshown in Table 21, some aspects of memory decline more with age than do

others (La Rue 1992;Prull et al. 2000).Short-term or immediate memory re-mains stable or declines to a modest degree in later life. For example, the medianforward digit span for healthy persons in their 80s is six items, compared withseven items for persons in their 30s (Wechsler 1997). On more demanding testsof short-term memory, such as recalling information after an interfering mes-sage, age differences favoring the young are likely to be observed, which coin-cides with the declines in working memory discussed earlier.


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Table 22. Cognition in normal aging: moderating variables

Genetic factors About 50% of cognitive variability in old age can be trac

Health Optimally healthy elderly persons outperform those with m

Education Education accounts for up to 30% of cognitive variabilit

Mental activity Mentally stimulating activities correlate with higher cognlongitudinal decline.

Physical activity Aerobic fitness is associated with better cognitive perform

Expertise Aging experts may develop compensatory strategies to maisome erosion in underlying cognitive skills.

Personality and mood Depression correlates with self-perceived memory failuresymptoms are severe.

Social and cultural milieu Everyday memory lapses may be judged more critically wby young adults.

Cognitive training Cognitively unimpaired older persons benefit from practic

Cohort effects Recently born cohorts are outperforming those born near tskills.

Sex differences Cognitive aging trends are similar for the two sexes, but wtasks at an earlier age than men, and men may show decthan women.

Racial and ethnic differences Performance differences favoring elderly white persons havbut when education is equated across groups, these diff


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Anecdotally, remote or long-term memory is well maintained in old age.

Research results are not so clear, partly because remote memory is difficult tomeasure because initial or intervening exposure to the material cannot be pre-cisely controlled (La Rue 1992;Prull et al. 2000).Overall, however, olderadults absolute levels of performance on remote-memory tests are often im-pressively high; for example, one study found that people recognized namesor photographs of more than 70% of high school classmates after an intervalof almost 50 years.

Another type of memory that shows minimal or modest age change is im-plicit or incidental recall. Incidental facts or features (e.g., the color of some-ones dress) can be recalled with about equal accuracy by young and old,whereas the old are more prone to forget information that they had explicitlyhoped to retain (e.g., the persons name).

Prospective memory (i.e., memory for actions intended in the future) showsdivergent age trends, depending on how and where it is measured (Henry et al.

2004).In laboratory settings, older adults typically do less well than youngerpersons. However, on naturalistic tasks (e.g., remembering to call to make anappointment), older adults often show superior follow-through, mainly becauseof more reliable use of external aids such as reminder notes.

The largest age decrements are observed in recent, episodic memory (LaRue 1992; Prull et al. 2000).Age differences favoring the young have beenfound on many explicit tests of recent memory, such as remembering items

on shopping lists, learning to associate pairs of words, copying designs frommemory, and remembering content of stories and conversations. On the av-erage, healthy older individuals make more mistakes than young adults onmemory items from mental status examinations, such as 5-minute delayed re-call of three or four simple words. On demanding explicit memory tasks,older persons recall less information initially compared with young adults,but their performance improves with repetition, and they retain most of what

they learn after delays and distractions. This ability to retain information,once it is acquired, is one of the best ways to distinguish normally aging mem-ory from that of patients with amnestic conditions or Alzheimers disease (seeChapter 5, Dementia and Alzheimers Disease).

Some of the problems that older people have with initial learning may be re-lated to strategies used for processing new information (La Rue 1992).Manyolder people take a more passive approach to learning and remembering than do


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Normal Aging 31

younger adults. For example, elderly people report less spontaneous use of mne-

monic strategies than do younger people and do not appear to capitalize as readilyon the organization inherent in words or actions as a basis for learning and recall.The shallower memory traces that result are subsequently harder to retrieve, espe-cially without the aid of reminders or cues. If older individuals are explicitly in-structed to use mnemonics or organizational strategies, their learning and recalloften improve dramatically, at least in the short term.

Active encoding and retrieval may require greater expenditure of effort and

energy than most older people can afford. Declines in effortful processing may becaused by altered neurotransmitter functions (especially catecholamines). Alterna-tively, such processing changes may be seen as an adaptive response to the dimin-ished demands of older adults everyday lifestyles. Also, it is important to note thatsome healthy and active elderly people do as well on demanding recent memorytasks as do more average young adults.

Older adults (and younger persons, too) often ask about ways to improve

their recall of everyday information. Mnemonic training can produce notablegains in troublesome areas, such as recall of names, locations of objects, and listsof things to be purchased or done, for old as well as young adults. Training is mostlikely to be effective for young-old persons as opposed to the oldest-old and forindividuals with no decline on mental status examination (Verhaeghen et al.1992). Training also works best in an individual or a small-group format and withrelatively short (e.g., half-hour) sessions as opposed to longer workshops or lec-

tures. Follow-up studies often show that people discontinue memory techniquesthey have learned within a few weeks. In some cases, this may simply mean thatthe training served its intended purpose (i.e., to prove that one can remembermore if need be), but it is also likely that the use of mnemonics may be too effort-demanding in the long run. A greater drawback of mnemonic training ap-proaches is that benefits often fail to generalize to everyday tasks not specificallyincluded in training (Ball et al. 2002).Education and counseling about memory

improvement is best approached from a broad perspective, in which improvingmemory is seen as part of an overall wellness plan.Of the many self-help books providing advice on how to maintain memory

function into old age, Keep Your Brain Young (McKhann and Albert 2002)isamong the best in terms of readability, breadth, and linkage to research. LearningThroughout Life (National Retired Teachers Association et al. 2004) is anothergood guide for the general reader. In The Memory Prescription,Small (2004) out-


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lines a 2-week program of diet, exercise, stress reduction, and mental exercise de-

signed to boost brain function. The program is derived from an ongoing programof research, but independent studies are needed to assess benefits of this approach.

Executive Function

The term executive functionrefers to cognitive abilities necessary for complex goal-directed behavior and adaptation to change. Some of the skills included in thiscategory are reasoning, planning, anticipating outcomes of behavior, directing at-

tentional resources in a flexible manner, monitoring ones own behavior, and self-awareness. Performance of such skills requires the coordinated activity of multipleregions of the brain and can be affected by injury to several different areas. How-ever, the prefrontal cortex and frontal-subcortical brain circuits have been shownto play a central role in executive functions. As noted earlier, normal aging has agreater decremental effect on these brain regions than on many other areas, andpredictably, age differences are relatively large on executive function tasks (see

Table 55 in Chapter 5, Dementia and Alzheimers Disease, for examples ofneuropsychological tests of executive function). Performance on executive func-tion tests correlates more closely than scores on many other cognitive tasks withactivities of daily living, and changes in executive function may play a role in de-termining which older people come to clinical attention for mild cognitivechanges (Royall et al. 2005).

Although research generally shows that older adults do worse than young or

middle-aged persons on both laboratory-based and practical reasoning tasks(Thompson and Dumke 2005), not all studies show this trend. For example, onerecent investigation found that cognitively healthy 65- to 74-year-olds providedmore relevant solutions to problem situationssuch as trying to improve theacrimonious tone of a meeting, dealing with excessive demands by ones sons tobabysit their children, or having blood drawn by a physician who is having diffi-culty with the procedurethan did a comparison group of 20- to 29-year-olds

(Artistico et al. 2003).In general, interpersonal problem solving is an area ofstrength for older people (Thompson and Dumke 2005).

Effect of Cognitive Change on Everyday Function

Although normal aging is accompanied by a variety of cognitive changes,most older adults are not impaired in everyday activities, even when relativelycomplex cognitive processing is required.


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Normal Aging 33

Several factors help to maintain daily function in the face of mild cognitive

decline (Park 1999).The very gradual nature of age-related change allows time toadjust to diminished speed and efficiency in cognitive function. The fact that gen-eral knowledge is well preserved in later life allows older adults to access a broadbase of information that is useful in solving problems and addressing everydayneeds. With practice, many tasks become automatic and require little cognitiveprocessing or effort to perform, and maintaining a familiar environment and rou-tine further reduces cognitive load. Also, many older adults make frequent and ef-

fective use of external cognitive aids such as writing reminder notes.Some areas, such as driving and monitoring medications, pose particularrisks (Park 1999). Older adults are more likely to be involved in accidents whiledriving than are younger persons, particularly in certain situations (e.g., leftturns in intersections). Cognitive research has identified a measure of peripheralvision (so-called useful field of vision) that is more predictive of driving successthan are standard visual acuity measures, and this research also has found that

older adults can improve driving skill through a combination of perceptualtraining and traditional drivers education classes (see Chapter 9, Competencyand Related Forensic Issues, for additional information on driving). Regardingmedications, it is important to note that some studies show better compliancewith medication regimens among older adults than among younger or middle-aged persons, particularly if the older adults are taking only a single medicationfor a long-standing condition (e.g., hypertension or arthritis). When they are

taking multiple medications that require dosing several times a day, the risk oferrors is increased, and it has been estimated that about 1% of acute hospitaladmissions for older persons are precipitated by medical errors or medicationreactions.

In industrialized nations, an overabundance of new information and rapidlychanging technologies place a heavy demand on learning skills. Older adultsbring to this situation a wealth of accumulated knowledge and experience, which

can facilitate learning of new information in areas of prior knowledge. One re-cent study found, for example, that older age proved to be an advantage in learn-ing new information about cardiovascular disease, presumably because of olderadults greater baseline knowledge of health-related subjects (Beier and Acker-man 2005). By contrast, younger adults were more adept at learning about a newtechnology. Research on training methods has shown that older adults learn bestwith self-paced training or other training environments that allow ample time to


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assimilate the information presented (Callahan et al. 2003).These modes of ed-

ucating most effectively remediate, or compensate for, reduced speed of process-ing and working memory or sensory limitations.

Clinical Implications of Cognitive Change

Cognitive declines that accompany normal aging complicate detection anddiagnosis of organic mental disorders. One common error is overdiagnosis ofdementia, particularly in persons with limited education. In one large multi-

cultural study, most old persons without dementia who had less than 5 yearsof education were rated with standard mental status examinations as impaired(Wilder et al. 1995).

Among healthy, well-educated old persons, brief cognitive screening mayfail to detect focal brain impairment or dementia in early stages. For example,as many as one in three older patients with mild Alzheimers disease who areotherwise healthy and have at least a high school education can be expected

to score in the normal range on very brief tests for cognitive screening.Outcomes of cognitive mental status examinations in older people mustbe interpreted cautiously, and the clinician should follow up with a morethorough diagnostic assessment for those who score in the impaired range orwhose adequate performance on a screening examination is inconsistent withlapses in everyday behavior. Paying attention to the pattern and types of errorsmay also help to distinguish normal from abnormal cognitive changes. Chap-

ter 5 (Dementia and Alzheimers Disease) provides more specific guidelinesfor screening for dementia through the use of cognitive mental status exami-nations, and the following subsection discusses more specific diagnostic issuesconcerning age-associated cognitive syndromes.

Age-related cognitive changes also have implications for the doctor-patientrelationship and for selection and monitoring of treatment. Extra care may berequired in explaining medical procedures to ensure informed decision mak-

ing. Asking the patient to repeat the main points and providing written sum-maries or illustrations may help to make details of procedures clear, althoughvery complicated medication organizers or instructional charts may be coun-terproductive.

In psychotherapy, the reduced pace of new learning and changes in rea-soning processes may result in a slower rate of clinical improvement. Often,this can be dealt with effectively by increasing the number of therapy sessions.


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Normal Aging 35

Abrupt changes in cognitive function always warrant medical attention.

Even more gradual declines, emerging over a year or two, may be an earlywarning of occult illness (so-called terminal decline) and should be carefullymonitored. According to one recent study, subclinical cognitive decline in-creases the risk of mortality in older men as much as a history of cancer does.

Diagnosing Age-Related Cognitive Change and MildCognitive Impairment

In DSM-IV-TR (American Psychiatric Association 2000) nomenclature, thecategory of age-related cognitive decline (780.9) may be coded to denotefunctioning of an older person with mild cognitive changes that are withinnormal limits for age and not attributable to a medical disorder.

No guidelines have been developed for identifying age-related cognitivedecline. However, diagnostic criteria have been proposed for a related, butnarrower, category of age-associated memory impairment (AAMI). Persons

with a diagnosis of AAMI must be 50 years or older, have subjective com-plaints of memory loss affecting routine activities, and perform below the av-erage level of young adults on a standardized memory test; exclusionarycriteria include any neurological, psychiatric, or medical disorders that couldreasonably be assumed to be producing the memory change. The prevalenceof AAMI based on objective assessment has been estimated to range from40% for persons in their 50s to 85% for those 80 and older (Larrabee and

Crook 1994). Thus, five of every six very old, healthy persons can be expectedto perform somewhat lower than young or middle-aged adults do on memorytests and possibly to have mild memory lapses in everyday activities. AAMIhas been shown to be stable over intervals of at least 4 years; thus, it is pre-sumed to reflect normal aging, as opposed to beginning dementia or otherbrain disorder.

Clinicians are also likely to see older adults whose cognitive skills are

somewhat worse than expected for their age but who are still coping well over-all and do not appear to have dementia. Much research has been devoted tothis gray area of performance, generally referred to as mild cognitive impair-ment. Diagnostic criteria for this condition are still evolving, and several def-initions have been proposed (seeWinblad et al. 2004).

The skill most commonly affected in mild cognitive impairment is learn-ing and recall of new information, but in some cases, problems are noted in


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other cognitive areas, such as language, visuospatial skills, or reasoning. The

term amnestic mild cognitive impairmentis used when memory is impaired,and the term nonamnestic mild cognitive impairmentis used for other types ofmild cognitive deficits. Additional subcategorization has been proposed todistinguish between cases in which a mild deficit is observed in a single do-main (e.g., memory) or in multiple domains (e.g., memory and reasoning).In all forms of mild cognitive impairment, there may be subtle difficulty withhigher-order activities of daily living such as financial management, but this

difficulty is often intermittent and can be dealt with by extra effort or com-pensatory approaches such as note taking or double-checking ones work.Table 23 compares diagnostic criteria for amnestic mild cognitive impair-ment with those for AAMI.

The very short tests included in mental status examinations are generallynot sensitive to mild cognitive impairment, and if this condition is suspected,referral for neuropsychological testing is recommended. To improve screening

accuracy for amnestic mild cognitive impairment, a more challenging test oflearning and memory should be incorporated into the psychiatric examina-tion (see Table 55 in Chapter 5, Dementia

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