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Position Statement 35: Aging Well: Wellness and Psychosocial Treatment for the Emotional and Cognitive Challenges of Aging
Aging is a time of diminishing mental as well as physical capacities, and cognitive aging is best understood as simply another phase of life. Some people age more successfully than others, and many find new and deeper satisfaction in later life. But aging also brings with it the threat of serious mental health conditions, including dementia as well as depression, anxiety and sometimes psychosis, which will require greater attention as our society ages. Mental Health America (MHA) advocates studying and funding medical and psychosocial interventions to help sustain our mental health and quality of life as we age, and acting to maintain and recover wellness.
In coping with the mental health conditions associated with aging, as with any other serious mental health condition, “recovery” should be the goal. While a positive attitude can make an enormous difference in aging well, mental illnesses including dementia, which the Diagnostic and Statistical Manual of Mental Disorders -5[i] (DSM) refers to as “mild” and “major” “neurocognitive disorders,” are not “normal” parts of aging, and should be identified and treated once it is clear that there is a probable disorder. This is as true with dementia as with any other mental health condition, though dementia has sometimes been thought of as different from other mental health conditions because it cannot be reversed.
Some confusion can be alleviated, some quality of living restored, by applying the lessons of “positive aging.”[ii] And people with all forms of dementia can benefit from psychosocial interventions, which Appendix A to this position statement examines in detail and contrasts with the relative lack of success in developing drugs to address dementia and related conditions. With better research and treatment, people can realistically hope to maintain better cognitive and emotional health in later life. MHA will refer to “positive aging” and “aging well” rather than “recovery” in the remainder of this position statement.
MHA urges that the budget discussions of all levels of government recognize the emerging needs of older people with mental health and substance use conditions, including cognitive health as a part of mental health. Innovative programs will be required to maintain and increase wellness as the American population goes through dramatic demographic change, and, “there is no health without mental health.” This issue should emerge as a major focus of health care reform implementation under the Affordable Care Act, to contain costs and encourage wellness by promoting “aging well.”
The overarching goals should be:
- to reduce isolation and enable older people with mental health or substance use problems to live where they prefer, generally in the community, as long as they can – to “age in place;”
- to assure access to clinically appropriate, culturally and linguistically competent care in the community and in congregate living settings for people who need more help as they grow older;
- to encourage people to age well by helping them to preserve their mental as well as general health and sense of vitality and fulfillment as they age;
- to prioritize public funding for psychosocial research and programs directed at aging well;
- to increase research into Alzheimer’s disease and other forms of dementia and especially the anxiety, depression and psychosis that sometimes accompany cognitive impairment; and
- to use all available regulatory tools and “nudges” to encourage pharmaceutical industry, academic and public interest study of out-of-patent and “off-label” drugs that can alleviate suffering.
The population of people over age 65 in the United States is projected to double between 2000 and 2030, from 35 million to 70 million.[iii] While mental illness is not an inevitable part of aging, and older people actually experience fewer mental health conditions (excepting cognitive impairment) as they age, approximately 6.9% of people aged 65-74 experience “frequent mental distress,”[iv] and many experience mental health and substance use conditions associated with loss of functional capacity even though a formal diagnosis may not be justified. Anxiety and depression and the psychotic symptoms of dementia in all its forms must be addressed for people to age well, and MHA envisions a supportive, integrated system of both psychosocial and medical care that encourages people to meet such challenges as they occur.
Older people with mental health problems are a diverse population including:
- people with lifelong serious and disabling mental illnesses;
- people with Alzheimer’s disease and other forms of dementia (often with co-occurring episodic anxiety, depression, and psychosis);
- people with severe depression, anxiety, and emotional and behavioral problems that contribute to high rates of suicide, social isolation, and preventable institutionalization;
- people with less severe disorders that nevertheless limit their ability to age well; and
- people who abuse substances, primarily alcohol and pain medications, but increasingly including people with lifelong addictions and those who use illegal substances recreationally.
As stated by Deborah Padgett in the conclusion to her Handbook on Ethnicity, Aging, and Mental Health, aging need not be a time of “irreversible decline and loss,” and depression and emotional distress can be mastered. She concludes: “Declines usually associated with aging are quite malleable and influenced less by aging per se than by a host of psychosocial and lifestyle factors such as stress, diet, and exercise. Among the [most important] psychosocial factors associated with successful aging are sense of control and autonomy and social support."[v] So “positive aging” can bring about overall wellness for individuals, focused on their personal goals and current place of residence, social support system, and community. The primary method is by strengths-based therapies[vi] that build the healthy habits that MHA refers to as “wellness.” These strengths and supports are critical to aging well.[vii]
For the same reason, Padgett explodes the “double jeopardy” concept that has stigmatized “ethnic aging.” After accounting for the underreporting common in minority communities, Padgett concludes that mental health conditions are no more prevalent in Black and Hispanic elders.[viii] In fact, she argues the contrary. Since, “adaptive [psychological, social and cultural strengths and] strategies formulated over a lifetime of struggle are keys to successful aging,”[ix] elders of color who have coped with deprivation and stigma over their entire lives may have better mastered the skills required to cope with late life challenges.
Still, nearly half of people over age 65 with a recognized mental or substance use disorder have unmet needs for services.[x] Older adults with mental health or substance use conditions often do not seek specialty mental health care. They are more likely to visit their primary care provider– often with a physical complaint.[xi] And though treatment can be an important component of aging well, misdiagnosis, especially by non-specialists, is a significant concern, as is overreliance on drugs rather than psycho-social treatment. The interaction among physical, emotional and behavioral conditions is complex in older people:
- Psychological stress may lead to general health problems;
- General health problems may lead to mental decompensation;
- Coexisting mental and general health challenges and responses may interact; and
- Social and psychosocial resources and medical and complementary treatments may affect all of the above.
Treatment works when older people are accurately diagnosed. But in older people, assessments of functional disabilities and prescriptions for concrete improvements in quality of life are more important than labels. By this definition, up to 80% of older people recover from depression with appropriate treatment.[xii] But more research is needed on the unique mental health issues associated with Alzheimer’s disease and other forms of dementia to achieve equivalent results with cognitive impairment and its psychiatric symptoms.
The ramifications of lack of access, misdiagnosis, and poor treatment reach beyond the mental well-being of the individual. There are serious physical consequences of untreated mental illness. Older people with chronic medical conditions such as diabetes and heart disease and co-occurring depression are at increased risk for disability, premature mortality, and high health care costs. In addition, people with serious mental illness are at high risk for obesity, hypertension, diabetes, cardiac conditions, respiratory problems, and communicable diseases that contribute to a life expectancy many years less than that of the general population.
Older people also face inevitable life challenges with emotional consequences such as disability, retirement, loss of status, reduced physical and mental abilities, losses of family and friends, and the inevitability of death. Older people with mental health challenges face these challenges with diminished resources and have to work harder to age well.
Older people with mental health or substance use problems are not yet a public policy priority, and MHA is only beginning to tear down this silo by recognizing the extent to which cognitive health as an essential aspect of mental health. In addition, because their needs usually overlap the mental health, substance abuse, general health, and aging services systems, the mental health concerns of elders often fall between the cracks. Specialized mental health and substance use services have not secured the resources necessary to provide appropriate care and treatment for older people. The general shift in mental health policy towards evidence-based, individual-centered care, consumer empowerment and recovery has not been reflected in improved services for older people. The primary and institutional care services that are the main source of care and treatment for older people with mental illnesses and substance use disorders rarely identify the particular needs and interests of this group. There is a widespread failure to integrate the aging, mental health and substance use treatment systems. A literature review shows the greatest support for community-based, multidisciplinary, geriatric mental health treatment teams.[xiii] But little of that is happening, yet.
Effective Services for Older People.[xiv] Evidence-based health care should be the foundation for building exemplary care tailored to needs of our aging population. Evidence-based health care:
- supports flexible and individualized care based on individuals’ unique needs, histories and other factors, and does not dictate “one-size-fits-all” treatment;
- develops research that is widely disseminated and vetted by advocates and people in treatment as well as researchers;
- develops research that appropriately represents all major cultural and linguistic groups so that group differences can be understood and addressed;
- focuses on prevention and treatment of Alzheimer’s disease and other forms of dementia and of the entire range of related mental health symptoms;
- emphasizes safety and quality of life as the overarching goals; and
- supports informed decision-making and positive aging as the principal determinants of care.
A comprehensive service system should include:[xv]
- outreach services, including community education and training, prevention and early intervention efforts, and screening and early identification;
- community-based, multidisciplinary, geriatric mental health treatment teams;
- comprehensive home and community based services, including integration with primary care, case management, peer and consumer-run services, caregiver supports, crisis services and long-term care;
- mental health promotion interventions that seek to improve the quality of life for older adults, not simply mitigate the negative effects of aging; and
- policy and legislative changes that address the problems of workforce development, funding, research, coalition-building and integrated service systems.
Integration of care is the key:
The vast majority of older adults with a mental health or substance use disorder also have other chronic conditions. Thus, it is critical to integrate mental health and substance use with other health services including primary care, specialty care, home health care, and residential-community-based care. There are various models for integrating mental health and general health services including:
- training primary care providers in mental health, co-locating health and mental health services, using integrated treatment teams of health and mental health professionals;
- using care managers to follow up with consumers outside of the office;
- establishing primary care centers that specialize in serving older adults with mental disabilities, establishing health satellites at mental health centers;
- using peers, or people with similar lived experience, to provide support to individuals with health and mental health problems; and
- using community-based, multidisciplinary, geriatric mental health treatment teams.
The “health home” and “accountable care organization” concepts embedded in the Affordable Care Act are the most recent federal initiatives promoting integration of care.[xvi] As of 2015, there were 744 ACOs, serving 7.8 million Medicare “lives.”[xvii]
The growth of ACOs slowed in 2014, and there are numerous barriers to sustaining these approaches, especially in the Medicare population, including:
- Providers lack knowledge of the various models for integrating mental health, substance use and general health services;
- Integration runs counter to the current service traditions. Providers tend to work independently rather than in collaboration;
- Older people’s mental health needs are not usually integrated into their overall discharge plan when they leave inpatient treatment;
- Cost can constrain options, as Medicare, Medicaid, and private insurance may not adequately reimburse for mental health and substance use services or collaborative care; and
- Research has not adequately addressed the psychosocial and pharmacological needs of older people, especially people with psychiatric symptoms that are associated with cognitive impairment.
Older people with mental health or substance use problems also often receive services and supports through social service agencies specializing in aging services. These include senior centers, case management, adult day care, and adult protective services. Unfortunately, there is currently a lack of cross-system knowledge and collaboration. Professionals who work in the specialty mental health, substance abuse, general health, or aging systems typically do not know about the services available in other systems, making it difficult to find appropriate services for older people.
Workforce Development. The behavioral healthcare system is not ready for the elder boom, which is predicted to hit in full force as the baby boomers retire. The diminishing workforce trained in geriatric mental health issues is of particular concern. Although peer support has shown its worth with younger adults, it has yet to be widely adapted to older people in need of assistance and support. Research supporting the use of peer support with this population is needed, along with training and implementation of this new workforce. It is also imperative that training in geriatric mental health be expanded and incorporated into curricula for health care professional education, especially for physicians, nurses, psychiatrists, psychologists, social workers, mental health counselors, peer specialists, and rehabilitation specialists. Currently there are roughly 2,425 geriatric psychiatrists in the United States with an estimated current need for 4,400 and a future need for 8,840. In regards to geriatric social workers, there are only 6,000 nationwide with a current need for 32,600 and a future need for 65,480.[xviii]
The Dementia Dilemma. In addition to mental health conditions, older people suffer from Alzheimer’s disease and from the eight other “neurocognitive disorders” identified in the DSM according to their “medical causes,” though the more recent literature has cast some doubt on those distinctions. Older people also experience what the DSM calls “mild neurocognitive disorders,” lesser declines in mental acuity often referred to as “mild cognitive impairment,” which may range from absent-mindedness to serious loss of mental functioning. An excellent 2015 summary, written in plain language by Berkeley Wellness, a publication of the University of California, can be found at http://www.berkeleywellness.com/healthy-mind/memory/article/could-we-stop-alzheimers?s=EFA_151003_AA1&st=email&ap=ed
The defining characteristic of dementia is significant impairment in activities of daily living. Most often, the clinical formulation of dementia is linked primarily to cognition, although such intellectual changes are often associated with behavioral changes, ranging from irritability and agitation to psychosis with hallucinations and delusions. Early onset Alzheimer’s disease is more easily defined as a distinct disease, but late onset dementia is often a mixed pathology. Plaques and tangles are not unique to Alzheimer’s disease. The overlapping and labile symptoms and physiological markers of dementia are such that controversy continues over the capacity to distinguish Alzheimer’s disease, even with a PET scan or in an autopsy, from the other forms of dementia identified in the DSM: Huntington’s disease (a genetic disorder that is better identified through genetic testing), Parkinson’s disease, Lewy body disease,[xix] frontotemporal degeneration, traumatic brain injury (identified from the injury rather than a brain scan), prion (“mad cow”) disease, HIV infection (identified by viral load tests), and vascular disease (atherosclerosis or “hardening of the arteries). Our diagnostic categories will surely evolve as we learn more.
This means that as people age, wellness matters more, not less, making activities like exercise, a good diet, reading, art, music, social interaction, study and service increasingly important even as the inertia of our aging bodies heads for the couch and the television set. Anyone who lives long enough will experience the struggles of cognitive aging, whether or not diagnosed with the dementia label. But the loss need not swallow up the person, no matter what the label, and effort can produce results.
Despite the fervent hope of Alzheimer’s advocates, there is no pill on the horizon that is likely to cure Alzheimer’s disease or any other form of dementia. At best, symptoms may be delayed and complications averted. Nor is Ginkgo biloba[xx] or any other substance going to prevent the aging of the brain, though some people may be helped by a variety of interventions that should be more studied and better understood. But cognitive impairment can in fact be slowed by a supportive system of psychosocial care grounded in the logic of positive aging. The emerging issues in the treatment of dementia are addressed in Appendix A to this position statement.
A Better Future
This analysis brings us full circle. Although some hope is held out for new drug or genetic therapies, Appendix A shows that psychosocial and public health measures are more effective in treating dementia. As Peter Whitehouse concluded in a recent essay:
Psychosocial interventions such as caregiver education, support groups, arts interventions, and other community programs have been demonstrated to improve quality of life. No drugs have been demonstrated to do the same (George and Whitehouse, 2010, Whitehouse and George, 2014, Portacone, Berridge, Johns, and Schicktanz, 2013, D’Alton, Hunter, Whitehouse, Brayne, and George, 2014, Katz and Meller, 2013).[xxi]
Having a sense of purpose and a community network in which to manifest that purpose seems to be important for brain health, an important component of aging well. But positive aging starts with more basic work --
- Stay Positive.
- Get Physically Active.
- Get Enough Sleep.
- Eat Well.
- Connect with Other People.
- And Take Care of Your Spirit.
Call to Action
- Aging well is everyone’s business. A positive aging agenda will require dramatic expansion of available services—including:
- access to appropriate housing and social supports;
- a focus on quality of life and person-centered goals;
- integration of care among the mental health, health, substance use, and aging services systems;
- building a much larger clinically and culturally/linguistically competent workforce; and
- increasing and re-inventing funding sources to develop a match between funding mechanisms and service needs.
- Health care reform is a promising avenue for promoting positive aging. Aging well and specialized behavioral, cognitive and emotional health needs should be priorities in the care of older people under the Affordable Care Act and in any changes made to Medicare.
- Affiliates are urged to adopt an aging well agenda for their communities, and promote it in partnership with others, since many services, especially housing, will need to be provided by local and state governments and nonprofit agencies.
- Affiliates may act as catalysts to make elder cooperative and congregate care more available in their communities.
- Research is urgently needed to understand the causes of Alzheimer’s disease and other dementias and how to prevent and treat both the dementia itself and the depression, psychosis and anxiety that often accompanies it. Affiliates should encourage the development of community-based psychosocial programs to meet these emerging needs.
- The federal, state and local governments and non-profit agencies and foundations should fund demonstration projects to explore new psychosocial treatments for dementia and co-occurring conditions and to improve the evidence base for those that exist. Psychosocial treatments have been shown to be more effective than drug therapies and should be promoted and used more extensively in the absence of approved drug therapies and in recognition of the substantial adverse side effects of the off-label drug therapies now being used.
- MHA urges much more research and public education concerning cholinesterase inhibiters, glutamate antagonists, antidepressants, antipsychotics and anxiolytics for use in dealing with dementia and its symptoms and co-occurring conditions. See Appendix A for more details.
- If additional authority is needed for the FDA to insist on full disclosure and additional studies of drugs being marketed and used off-label as frequently as are antipsychotics and benzodiazepines, MHA strongly supports congressional action to grant such authority. In addition, the FDA should use the full range of enforcement incentives and “nudges” that it can devise to get these drugs properly evaluated and controlled. Academic researchers and public interest organizations like the Cochrane Collaboration should be recruited to help.
- MHA urges the pharmaceutical industry to help build and publicize an evidence base to help people with dementia who lack access to on-label medications to treat psychotic symptoms and anxiety.
Appendix A:Treatment of Cognitive Aging and Dementia
[i] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders -5 (American Psychiatric Publishing 2015).
[ii] Hill, R.D., Positive Aging (W.W. Norton & Co. 2005) quotes Seligman, M.E.P. & Csikszemmihalyi, M, “Positive Psychology: An Introduction,” American Psychologist 55:5-14 (2000) in defining the term, focused on well-being, contentment, satisfaction, hope, optimism, and happiness. According to Hill, the traits to be emphasized are: “the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future-mindedness, spirituality, high talent, and wisdom.” Introduction, at p. xi-xii.
The terminology of “positive aging” is a more recovery-oriented version of the earlier term, “successful aging.” Even a person with one or more chronic conditions can age positively -- if not fully successfully. And even “negative aging” is far preferable to “pathological” or “diseased” aging, the terms formerly in use. According to Hill, positive aging has four characteristics: “a person mobilizes resources to cope with age-related decline; a person makes lifestyle choices to preserve well-being; a person cultivates flexibility across the life span; and a person focuses on the positives versus the problems and difficulties of growing old.” Id. at 18-23.
[iii] U.S. Bureau of the Census, “Population Projections of the United States by Age, Sex, Race and Hispanic Origin: 1995-2050, Current Population Reports, P25-1130 (2000).
[iv] Segal, D.L., Qualls, S.H., & Smyer, M.A., Aging and Mental Health (2nd ed.), (Wiley-Blackwell, 2011), at 7, quoting the CDC (2007). People aged 75 and older actually had less frequent severe symptoms.
[v] Padgett, D.K., ed., Handbook on Ethnicity, Aging and Mental Health (Greenwood Press, 1995), at pp. 304-5.
[vi] See Vickers, R., “Strengths-based Health Care: Self-advocacy and Wellness in Aging,” in Mental Wellness in Aging, Ronch, J.L., and Goldfield, J.A., eds. (Health Professions Press, 2003)
[viii] Padgett, supra, at 306. Other groups have not been adequately studied.
[x] George, L.K., Blazer, D.G., Winfield-Laird, I., et al., “Psychiatric Disorders and Mental Health Service Use in Later Life,” in Epidemiology and Aging, Edited by Brody, J.A. and Maddox, G.L. (Springer, 1988)
[xi] U.S. Department of Health and Human Services, Older Adults and Mental Health: Issues and Opportunities (Rockville, MD: 2001).
[xii] See generally, Segal, D.L., Qualls, S.H., & Smyer, M.A., Aging and Mental Health (2nd ed.), supra.
[xiii] Bartels, S.J., Dums, A.R., Oxman, T.E., Schneider, L.S., Areán, P.A., Alexopoulos, G.S. & Jeste, D.V., “Evidence-based Practices in Geriatric Mental Health Care,” Psychiatric Services 53(11):1419-1431 (2002). http://psychservices.psychiatryonline.org/cgi/reprint/53/11/1419
[xiv] National Association and Mental Health Planning and Advisory Councils, Older Adults and Mental Health: A Time for Reform. DHHS Pub. No. (SMA), Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. (2007), no url available.
[xvi] See MHA Position Statement 71, Health Care Reform, http://www.mentalhealthamerica.net/positions/health-care-reform
[xvii] Muhlestein, D. “Growth and Dispersion of Accountable Care Organizations in 2015,” Health Affairs BloG (March 31, 2015, http://healthaffairs.org/blog/2015/03/31/growth-and-dispersion-of-accountable-care-organizations-in-2015-2/
[xviii] Find Geriatric Psychiatrists, U.S. News and World Report Health (last visited January 25, 2016), http://health.usnews.com/doctors/location-index/geriatric-psychiatrists.
[xx] Ginkgo biloba is an ancient Chinese herbal remedy that has been shown to have significant neuroprotective effects, confirmed by all sources. However, two recent major studies and a Cochrane review cast doubt on the validity of the prior, smaller and shorter studies, and determined that in the aggregate the data do not support the use of ginkgo in the prevention of Alzheimer’s disease. The recent evidence is mostly negative, though the studies are still inconsistent. Although ginkgo has a mild effect in protecting against mild cognitive impairment/dementia, it probably does not prevent it. But all sources except one remain optimistic for some ongoing neuroprotective role for Ginkgo. http://www.mentalhealthamerica.net/mentalhealthandcam
[xxi] Whitehouse, P.G.. “The Diagnosis and Treatment of Alzheimer’s: Are We Being (Ir)Responsible?” Unpublished monograph supplied by and on file with the author (August 19, 2015).