New directions in mental health care for older adults

The aging of the population, shifting diagnostic criteria, and new health care policy initiatives are some of the factors driving changes in mental health treatment for older Americans, according to the September special issue of the Harvard Review of Psychiatry.

"Both workforce shortages and fiscal pressures have presented obstacles to caring for the behavioral needs of our elderly," according to a guest editorial by Drs. James Ellison of Christiana Care Health System, Wilmington, Del., and Brent Forester of McLean Hospital, Belmont, Mass. The special issue presents a timely update on the trends and developments leading to new directions in mental health care for older adults.

Updates on Mental Health Diagnosis and Treatment of Older Adults

Recent years have seen a phenomenal transformation in the field of geriatric psychiatry, as older adults now comprise more than 13 percent of the US population. Among other trends, the Affordable Care Act introduced measures to integrate behavioral health treatment into primary care settings, with the aim of increasing the availability and effectiveness of care.

The special issue presents seven papers by noted experts, who discuss the policy changes, new diagnostic classifications, and latest research driving change in the mental health care of older adults. Topics include:

• Changes in the healthcare landscape, including nine "key initiatives" that provide opportunities for assessing and treating older adults with mental health disorders, as well as for funding outcomes-based research. Emerging technologies such as telehealth, smartphone health apps, and social media may provide new approaches to improving outcomes while reducing costs.
• New diagnostic criteria, based on the recently revised DSM-5. These include the new diagnosis of "hoarding disorder"; a newly defined category of neurocognitive disorders that includes "major neurocognitive disorder" (replacing the term dementia), "mild neurocognitive disorder," (replacing mild cognitive impairment), and delirium; and other diagnostic criteria changes that will increase the accuracy of assessment of common mood disorders.
• Age-related differences in the prevalence and characteristics of anxiety disorders. These symptom differences—along with the effects of accompanying medical disorders—may contribute to the challenges of assessing anxiety in older adults.
• New approaches to the problem of depression in later life. A palliative care approach has gained increasing support among caregivers who treat terminal disorders in the elderly. Instead of emphasizing the aggressive search for curative treatments, palliative care prioritizes quality of life, a change in focus that often leads to longer survival as well as greater comfort.
• The many and varied causes of psychosis—often related to underlying medical or neurological conditions. New evidence on the appropriate use of antipsychotic medications in older patients with neurocognitive, psychotic, or mood disorders is summarized as well.
• An in-depth focus on the new DSM-5 category of "mild neurocognitive disorder." While more research is needed to clarify this new diagnostic category, it reflects the growing emphasis on early recognition and treatment of cognitive impairment.
• Management of behavior changes and neuropsychiatric symptoms in older adults with Alzheimer's disease or other neurocognitive disorders. Alternatives to antipsychotic medications, including nondrug approaches, may provide urgently needed new treatments.

Drs. Ellison and Forester believe their special issue will provide "both scholarly and practical information for geriatric specialists and generalists interested in the care of older adults." They conclude, "The reader of these reviews will come to appreciate how research into the pathophysiology of behavioral disorders in later life is helping to suggest more specific and effective treatment approaches and, indeed, deepening our understanding of mental health and illness throughout the life cycle."