Introduction

The aging population continues growing in number, diversity and mental health needs. Estimating the current mental health workforce serving older adults remains challenging. Nonetheless, a common consensus is the current workforce is insufficient to meet current and anticipated future demand.

This publication is designed to provide psychologists and other health care practitioners with resources, tools and information to enhance their work with older adults (defined as persons 65 years of age and older). It is intended to serve as a resource in response to the Institute on Medicine's 2011 report, "The Geriatric Mental Health and Substance Use Workforce: In Whose Hands?" that highlights the necessity of increasing the geriatric workforce to address mental health and substance use needs of older adults.

The publication utilizes the framework of and summarizes the guidance offered in the 2013 APA Guidelines for Psychological Practice with Older Adults.  It links readers to the complete set of APA guidelines and additional resources for those currently working with older adults or hoping to work with this population in the future.

For practitioners who wish to specialize in professional geropsychology, more detailed guidance is available in the “Pikes Peak Attitudes, Knowledge and Skills Competencies for Practice in Professional Geropsychology," and the corresponding competencies assessment tool developed by the Council of Professional Geropsychology Training Programs.

Why Practitioners Need Information About Working with Older Adults

People 65 years old and older are the fastest growing segment of the U.S. population. By 2030, older adults will account for 20 percent of our nation's people, up from 13 percent in 2008. Despite the broad range of exciting opportunities for practice with older adults, not enough practitioners exist to keep pace with the increasing demand for psychological services.

Mental health providers can be valuable resources in the education and training of other health and aging professionals, direct care workers, members of interprofessional teams and families and caregivers of older adults. Moreover, even if a professional does not work directly with older adults, related issues may arise in work with younger clients (e.g., caregiving for aging parents, grandparents raising grandchildren).

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Competence in and Attitudes toward Working with Older Adults

Many presenting issues for older adults are similar to those of middle-aged adults and generally respond to the appropriate evidence based treatments offered by mental health professionals. However, some mental health problems may be more prevalent among older adults than younger adults and symptoms may manifest differently across the lifespan (e.g., anxiety, depression), thus requiring modifications to treatment approaches. The shared and unique factors to consider when providing mental health treatment to older adults make the field highly rewarding and challenging.

There are many inaccurate stereotypes of older adults that can contribute to negative biases and adversely affect the delivery of psychological services. Older adults themselves can also harbor negative age stereotypes, which have been found to contribute to an array of adverse outcomes (e.g., worse physical performance, memory performance and even reduced survival). Furthermore, these negative stereotypes can adversely affect health care providers' attitudes and behaviors toward older adult clients. To reduce biases that can impede their work with older adults, it is important for providers to examine their attitudes toward aging and older adults. As some age-related biases may result in professional “blind spots,” it is often useful to seek consultation from colleagues who are experienced in working with older adults. Providing culturally competent treatment includes awareness of and sensitivity to aging, a universal process influenced by health, demographics, experience and cultural beliefs.

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Commonly Held Myths About Older Adults
Myth: Dementia is an inevitable part of aging.
Fact: Most older adults are cognitively intact.
Myth: Older adults have higher rates of mental illness than younger adults, especially depression.
Fact: Older adults tend to have lower rates of depression than younger adults.
Myth: Older adults are a homogeneous group.
Fact: The aging population is a highly heterogeneous group.
Myth: Most older adults are frail and ill.
Fact: Most older adults have good functional health.
Myth: Older adults have no interest in sex or intimacy.
Fact: Most older adults have meaningful interpersonal and sexual relationships.
Myth: Older adults are inflexible and stubborn.
Fact: Most older adults have the same personality traits as at a younger age.
General Knowledge About Adult Development, Aging and Older Adults

There are a variety of conceptions of “successful” late adult development. Inevitably, aging includes the need to accommodate to physical changes, functional limitations and other changes in psychological and social functioning, although there are significant individual differences in the onset, course and severity of these changes. The majority of older adults adapt successfully to these changes.

A lifespan developmental perspective is an important framework for guiding the work of mental health practitioners. Psychological and social resilience is developed over the course of a lifetime. Recognition of this can help practitioners to engage the strengths of older clients to effectively address current late life problems. Practitioners working with older adults find it useful to be cognizant of the strengths that many older people possess including the opportunities for using skills and adaptations they have developed over their lifespan for continued psychological growth in late life.

Practitioners working with older adults are encouraged to understand normal biological changes that accompany aging. Despite considerable individual differences, older adults almost inevitably experience changes in sensory acuity, physical appearance and body composition, hormone levels, peak performance capacity of most body organ systems, and immunological responses and increased susceptibility to illness. Disease accelerates age-related decline in sensory, motor and cognitive functioning, whereas lifestyle factors may mitigate or moderate the effects of aging on functioning. It is useful for the practitioner to distinguish normative patterns of change from non-normative changes, and to determine the extent to which an older adult’s presenting problems are symptoms of physical illness, or represent the adverse consequences of medication. This information aids in devising appropriate interventions.

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Diversity in the Aging Process

The older adult population is highly diverse and is expected to become even more so in the coming decades. The heterogeneity among older adults surpasses that seen in other age groups. Psychological issues experienced by older adults may differ according to factors such as age cohort, gender, race, ethnicity and cultural background, sexual orientation, disability status, rural/frontier living status, education and socioeconomic status, and religion.

Age intersects with other aspects of diversity (e.g., 75-year old, low-income, self-identified lesbian with osteoarthritis). Persons with multiple minority statuses have often suffered discrimination from the larger society, including from the mental health professions. Discriminatory life experiences can result in health disparities. Practitioners are encouraged to consider these factors in providing culturally sensitive mental health services.

Emerging cohorts of older adults (e.g., “baby boomers”) are likely to have generational perspectives that differentiate them from earlier and later cohorts, and these generational perspectives will continue to profoundly influence the experience and expression of health and psychological problems.

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Clinical Issues

In general, most older adults have good mental health. However, prevalence estimates suggest that 20-22 percent of older adults meet criteria for a mental disorder. Some older adults may have a recurrence of psychological disorders from earlier in life or develop new problems because of unique age-related stressors or neuropathology. Others may have histories of chronic mental illness or personality disorders, which may change in presentation because of other factors (cognitive impairment, medical comorbidity, polypharmacy and end-of-life issues). Many older adults have significant psychological symptoms that are less impairing or distressing, but remain important to address. Rates may be even higher among older adults in residential facilities.

Some mental health disorders have unique presentations in older adults. For example, late-life depression may have a relative emphasis on somatic rather than emotional symptoms. Anxiety disorders, while relatively common in older adults, are not part of normal aging. Symptoms are typically similar to those of young adults, but the content of older adults' fears and worries tend to be age related (e.g., health concerns).

Older adults are at increased risk for alcohol-related problems due to age-related physiological changes. Approximately 2.2 percent of older men and 1.4 percent of older women report using illicit drugs such as cocaine, heroin and marijuana and this rate is expected to increase as baby boomers age.

For most older adults, normative age-associated changes in cognition are mild and do not significantly interfere with daily functioning. However, an appreciable minority of older adults suffers impaired cognition that adversely impacts functional abilities. Older adults living with dementia may evidence coexistent psychological symptoms (e.g., depression, anxiety, paranoia, behavioral disturbances). As functional ability declines, the environment becomes increasingly important in maximizing the older adult's functioning and ability to maintain their quality of life.

Familiarity with the prevalence of mental disorders in late life, their symptom presentation and their relationship with physical health problems will facilitate accurate recognition of and appropriate therapeutic response to these and other syndromes.

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Assessment of older adults

Ideally, a geriatric assessment is conducted by an interdisciplinary team to insure a comprehensive view of the individual. A thorough evaluation will focus on both strengths and weaknesses, determining how problems interrelate and taking account of contributing factors. In evaluating older adults it is useful to ascertain the possible influences of various factors that may affect presentation of psychological disorders, including medications, medical disorders, environmental factors (including the testing environment) and interpersonal relationships. Relevant methods for assessment of older adults may include clinical interviewing, use of self-report measures, cognitive performance testing, structured behavioral or environmental observations, psychophysiological techniques, neuroimaging and use of informant data.

Practitioners are encouraged to consider methods of assessment appropriate for older adults. This includes using standardized measures shown to be reliable and valid with this population and/or measures with age appropriate normative data. It is also important to consider the impact of sensory impairments, living contexts, and cultural background of older adults during the assessment. In particular, it behooves practitioners to consider potential confounds that may affect performance including sensory deficits, disability, language barriers or lack of access to resources (e.g., formal education) and to select culturally appropriate assessment instruments as available. When assessing older adults, practitioners must consider their multicultural competence. This includes consideration of the older adult's ethnic, racial and cultural background but also other factors, such as degree of health literacy and prior experience with mental health providers.

Practitioners may be asked to help determine the nature of and bases for cognitive difficulties, functional impairment or behavioral disturbances. Cognitive screening typically involves use of brief instruments to identify global impairment with high sensitivity but with relatively low diagnostic specificity. Practitioners are encouraged to be proficient in the functional assessment of strengths and limitations in activities of daily living (such as bathing) and independent activities of daily living (such as managing finances) in the context of environmental demands and supports. For older adults living in structured environments, it is important to consider if and how the physical/social environment and organizational culture may hinder or promote their functioning and general well-being.

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Intervention, Consultation and Other Service Provision

Research shows that older adults respond well to a variety of forms of psychotherapy and can benefit from psychological interventions to a degree comparable with younger adults. Multiple evidence-based therapies have demonstrated utility in the treatment of depression, anxiety, sleep disturbance, pain, sexual issues, alcohol abuse and interpersonal relationship difficulties. There is also evidence that psychological interventions are effective in reducing depression and behavioral disturbances, and improving functional abilities, among cognitively impaired older adults. Other interventions unique to older adults include reminiscence therapy and life review, grief therapy and psychoeducational programs for older adults, family members and other caregivers. Services may occur in a variety of settings, ranging from the older adult's own home to outpatient settings, day programs, inpatient medical or psychiatric hospitals, assisted living and long-term care residences or even the criminal justice system.

Practitioners may also contribute to the health and well-being of older adults by becoming involved in broader prevention efforts and other community-oriented interventions. Accurate understanding of the professional roles and services, regulatory requirements and operational challenges faced by other professionals can be important when providing effective interdisciplinary collaboration. In consultation to other professionals, institutions, agencies and community organizations, practitioners may play key roles in the training and education of staff working directly with older adults. The ability to communicate, educate, and coordinate with other concerned individuals (e.g., providers, family members) may often be a key element in providing effective mental health services to older adults.

Ethical and legal issues may also arise while providing services to older adults (e.g., issues of confidentiality within families and facilities). It is important that practitioners strive to ensure the right that the older adults they serve direct their own lives. A common values conflict involves older adults who are moderately to severely cognitively impaired and may be in some danger of causing harm to self or others. Even when cognitive impairment does interfere with a person's ability to exercise autonomy in the present, it may remain possible to ascertain what the individuals' values are or have been in the past and act according to those values.

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Professional Issues and Education

As the need for mental health services grows in the older population, additional geriatric health care providers will be required. Practitioners are encouraged to pursue continuing education to develop and enhance their competence in providing mental health services to older adults.

Additionally, those working with older adults are encouraged to remain alert to changes in health care policy and practice that will impact practitioners' professional work. Knowledge of Medicare and Medicaid can be useful, as some states provide reimbursement for mental health services for older adults who have both Medicare and Medicaid (“dual eligibles”). Practitioners may also benefit from knowledge about Social Security, through which the vast majority of older adults receive income, and the array of other social supports and services available to older adults. These include familiarity with the local area agency on aging, home and community based aging services provided by the Older American's Act, and other community resources.

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Useful Resources
Authors

The document "What Practitioners Should Know about Working with Older Adults" was developed in 1997 as an initiative of APA President Norman Abeles by the APA Working Group on the Older Adult Brochure. The document was revised to align with the APA Guidelines for Psychological Practice with Older Adults (2013) by the 2013 and 2014 APA Committee on Aging.

Members of the 1997 APA Working Group on the Older Adult Brochure

Susan Cooley, PhD
Irene M. Deitch, PhD
Mary S. Harper, RN, PhD
Gregory A. Hinrichsen, PhD
Martita A. Lopez, PhD
Victor A. Molinari, PhD 

Members of the 2012-2013 APA Guidelines for Psychological Practice with Older Adults Revision Working Group

Gregory A. Hinrichsen, PhD (Chair)
Adam Brickman, PhD
Barry Edelstein, PhD
Kimberly Hiroto, PhD
Tammi Vacha-Haase, PhD
Richard Zweig, PhD

Members of the 2013 and 2014 Committee on Aging

Lisa Brown, PhD
Brian Carpenter, PhD
Kelly O'Shea Carney, PhD
Manfred Diehl, PhD
Kimberly Hiroto, PhD
Jennifer Moye, PhD
Karen Roberto, PhD
Glenn Smith, PhD