Handbook of Mental Health and Aging

970 Pages·1992·14.941 MB·English

by  James E. Birren, Gene D. Cohen, R. Bruce Sloane, Barry D. Lebowitz, Donna E. Deutchman, May Wykle and Nancy R. Hooyman (Eds.)

Handbook of
Mental Health and Aging
Second Edition
Editors
James E. Birren R. Bruce Sloane Gene D. Cohen
Borun Center for Department of Psychiatry National Institute on Aging
Gerontological Research University of Southern California Bethesda, Maryland
University of California Medical Center
Los Angeles Los Angeles, California
Los Angeles, California
Associate Editors
Nancy R. Hooyman Barry D. Lebowitz May Wykle
School of Social Work National Institute Gerontological Nursing
University of Washington of Mental Health FPB School of Nursing
Seattle, Washington Rockville, Maryland Cleveland, Ohio
Editorial Coordinator
Donna E. Deutchman
Borun Center for
Gerontological Research
University of California,
Los Angeles
Los Angeles, California
Academic Press, Inc.
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Front Cover Photograph: Sculpture of Old Woman and Young Man by
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This book is printed on acid-free paper. 0
Copyright © 1992,1980 by ACADEMIC PRESS, INC.
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Library of Congress Cataloging-in-Publication Data
Handbook of mental health and aging / edited by James E. Birren, R.
Bruce Sloane, Gene D. Cohen. — 2nd ed.
p. cm.
Includes bibliographical references and index
ISBN 0-12-101277-8
1. Geriatric psychiatry—Handbooks, manuals, etc. 2. Aged—Mental
health-Handbooks, manuals, etc. 3. Aged-Psychology-Handbooks,
manuals, etc. I. Birren, James E. II. Sloane, R. Bruce, date.
III. Cohen, Gene D.
[DNLM: 1. Aging. 2. Mental Disorders-in old age. WT 150 H2355]
RC451.4.A5H38 1991
618.97'689-dc20
DNLM/DLC
for Library of Congress 91-41083
CIP
PRINTED IN THE UNITED STATES OF AMERICA
92 93 94 95 96 97 HA 9 8 7 6 5 4 3 2 1
Contributors
Numbers in parentheses indicate the pages on which the authors' contributions begin.
Ahmed Aboraya (27), Fellow, Psychiatric Epidemiology and Aging, The Johns Hopkins University,
Baltimore, Maryland 21205
James C. Anthony (27), Department of Mental Hygiene, The Johns Hopkins University, Baltimore,
Maryland 21205
Roland M. Atkinson (515), Veterans Affairs Medical Center, Portland, Oregon 97201, and Depart-
ment of Psychiatry, School of Medicine, Oregon Health Sciences University, Portland, Oregon
97201
Michael J. Bernstein (515), Veterans Affairs Medical Center, Portland, Oregon 97201, and Depart-
ment of Psychiatry, School of Medicine, Oregon Health Sciences University, Portland, Oregon
97201
Dan G. Blazer (379), Department of Psychiatry, Duke University Medical Center, Durham, North
Carolina 27705
Daniel J. Buysse (557), Fleet Evaluation Center, Pittsburgh, Pennsylvania 15213
Eric D. Caine (603), UR-NIMH Clinical Research Center for the Study of Psychopathology of the
Elderly, Department of Psychiatry, University of Rochester School of Medicine and Dentistry,
Rochester, New York 14642
Gene D. Cohen (893), National Institute on Aging, Bethesda, Maryland 20892
Walter R. Cunningham (339), Department of Psychology, University of Florida, Gainesville, Flor-
ida 32611
Barbara C Du Bois (99), University Center on Aging, College of Health and Human Services, San
Diego State University, San Diego, California 92182
Spencer Eth (853), Department of Psychiatry and Biobehavioral Sciences, School of Medicine,
University of California, Los Angeles, California 90024, and Psychiatry Service, West Los
Angeles Veterans Affairs Medical Center, Los Angeles, California 90073
Barry Fogel (433), Center for Gerontology and Health Care Research, Brown University, Provi-
dence, Rhode Island 02912
Linda Ganzini (515), Veterans Affairs Medical Center, Portland, Oregon 97201, and Department of
Psychiatry, School of Medicine, Oregon Health Sciences University, Portland, Oregon 97201
Linda K. George (793), Department of Psychiatry and Center for the Study of Aging, Duke Univer-
sity Medical Center, Durham, North Carolina 27710
Gary L.Gottlieb (873), Department of Geriatric Psychiatry, Hospital of the University of Pennsyl-
vania, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania 19104
Cheryl L. Grady (201), Laboratory of Neurosciences, National Institute on Aging, Bethesda,
Maryland 20892
Hillel T. Grossman (603), UR-NIMH Clinical Research Center for the Study of Psychopathology of
xvi Contributors
the Elderly, Department of Psychiatry, University of Rochester School of Medicine and Den-
tistry, Rochester, New York 14642
Barry Gurland (229), Center for Geriatrics and Gerontology, Columbia University Faculty of Medi-
cine, New York State Office of Mental Health, New York, New York 10032
David Gutmann (75), Institute of Psychiatry, Northwestern University, Chicago, Illinois 60611
Kirsten L. Haman (339), Department of Psychology, University of Florida, Gainesville, Florida
32611
Carolyn C. Hoch (557), Fleet Evaluation Center, Pittsburgh, Pennsylvania 15213
Sidney Katz (229), Columbia University Faculty of Medicine, New York State Office of Mental
Health, New York, New York 10032
Bryan J. Kemp (671), Clinical Gerontology Service, Rancho Los Amigos Medical Center, Downey,
California 90242, and Rehabilitation Research and Training Center on Aging, Departments of
Psychiatry and Family Medicine and Gerontology, University of Southern California, Los An-
geles, California 90007
Harold G. Koenig (379), Department of Psychiatry, Duke University Medical Center, Durham,
North Carolina 27705
Asenath La Rue (643), Department of Psychiatry and Behavioral Sciences, University of California,
Los Angeles, California 90024
Lawrence W. Lazarus (699), Rush Medical School, Chicago, Illinois 60612
Barry D. Lebowitz (3), National Institute of Mental Health, RockVille, Maryland 20857
Gregory B. Leong (853), Department of Psychiatry and Biobehavioral Sciences, School of Medi-
cine, University of California, Los Angeles, and Psychiatry Service, West Los Angeles Veterans
Affairs Medical Center, Los Angeles, California 90073
Morton A. Lieberman (119), Center for Social Sciences, University of California, San Francisco,
San Francisco, California 94143
Benjamin Liptzin (833), Tufts University School of Medicine, Boston, Massachusetts, and Baystate
Medical Center, Springfield, Massachusetts 01199
Joan M. McDowd (307), Department of Psychology, University of Southern California, Los An-
geles, California 90089
Judith Mitchell (671), Rehabilitation Research and Training Center on Aging, School of Family
Medicine, University of Southern California, Los Angeles, California 90007
Timothy H. Monk (557), Fleet Evaluation Center, Pittsburgh, Pennsylvania 15213
David G. Morgan (175), Division of Neurogerontology and Department of Biological Sciences,
University of Southern California, Los Angeles, California 90089
Stephanie Nagley (815), Frances Payne Bolton School of Nursing, Case Western Reserve Univer-
sity, Cleveland, Ohio 44106
Joyce Nevis-Olesen (721), Harvard Medical School—Affiliated Teaching Hospitals, Boston, Mas-
sachusetts 02115
Nancy A. Newton (699), Chicago School of Professional Psychology, Chicago, Illinois 60605
George Niederehe (3), National Institute of Mental Health, Rockville, Maryland 20857
Sheryl Osato (643), Geropsychiatry Service, West Los Angeles VA Medical Center, Brentwood
Division, Los Angeles, California 90024
Harvey Peskin (119), San Francisco State University, San Francisco, California 94143
Elaine R. Peskind (477), Department of Psychiatry and Behavioral Sciences, University of Wash-
ington, School of Medicine, Seattle, Washington 98195
Jon Pynoos (763), Andrus Gerontology Center, University of Southern California, Los Angeles,
California 90089
Peter V. Rabins (463), Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of
Medicine, Baltimore, Maryland 21205
Contributors xvii
Stanley I. Rapoport (201), Laboratory of Neurosciences, National Institute on Aging, Bethesda,
Maryland 20892
Murray A. Raskind (477), Department of Psychiatry and Behavioral Sciences, University of Wash-
ington, School of Medicine, Seattle, Washington 98195
Victor Regnier (763), Departments of Architecture and Gerontology, University of Southern Cal-
ifornia, Los Angeles, California 90089
Charles F. Reynolds III (557), Fleet Evaluation Center, Pittsburgh, Pennsylvania 15213
Joel Sadavoy (433), Department of Psychiatry, University of Toronto, Baycrest Centre for Geriatric
Care, Toronto, Ontario M6A 2E1, Canada
Carl Salzman (721), Department of Psychopharmacology, Harvard Medical School, Massachusetts
Mental Health Center, Boston, Massachusetts 02115
Arnold B. Scheibel (147), Departments of Anatomy and Cell Biology, Psychiatry, and Brain Re-
search Institute, University of California, Los Angeles, Medical Center, Los Angeles, California
90024
Frank Schieber (251), Department of Psychology, Oakland University, Rochester, Michigan 48309
Mary E. Segall (815), Frances Payne Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio 44106
Marsha Mailick Seltzer (583), University of Wisconsin, Madison, and Waisman Center, Madison,
Wisconsin 53705
Javaid I. Sheikh (409), Department of Psychiatry and Behavioral Sciences, Stanford University
School of Medicine, Stanford, California 94305
E. Percil Stanford (99), University Center on Aging, College of Health and Human Services, San
Diego State University, San Diego, California 92182
Judith A. Sugar (307), Department of Psychology, Colorado State University, Fort Collins, Colo-
rado 80523
Hans Thomae (355), Department of Psychology, Langemarck 387, University of Bonn, 5300 Bonn
3, Germany
May H. Wykle (815), Frances Payne Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio 44106
Janet Yang (643), Department of Psychiatry and Behavioral Sciences, University of California, Los
Angeles, Los Angeles, California 90024
Preface
The first edition of the Handbook of Mental Health and Aging was published in 1980.
Supported by the National Institute of Mental Health, the first edition aimed to survey a
subject matter that was predicted to grow in significance. That prediction has proved to be
correct; the subject matter has grown enormously since the first edition. A dramatic
increase in the population of older persons has focused international attention on the well-
being of older persons—their mental and physical health. Advances in medicine and
increases in longevity have presented new concerns in the area of mental health and aging,
for example, how to treat the new and burgeoning population of persons with develop-
mental disabilities who are surviving into late life. Increasing life expectancy and trends
towards earlier retirement have meant that many people can expect to survive almost two
decades past retirement. Maintaining mental health and productivity during this period is
of critical importance.
In the scientific and professional communities there has been a marked increase in
research and an exponential growth in published literature. This is not evidence that the
mental health of older persons has improved, only that we are better equipped to study its
many aspects. This top-down view of the subject matter suggests that improvements can
follow if training of qualified personnel also becomes a higher priority in our professions
and sciences. However, the number of personnel devoted to study and service in mental
health and aging remains very small. While devoted primarily to the understanding of
phenomena of mental health and aging, we hope that this volume will contribute to an
improvement in the mental life of older adults and in the quality of life for the growing
millions of older persons.
The purpose of this Handbook is to provide authoritative reviews and reference sources
to the scientific and professional literature on mental health and aging. It is intended to be
a definitive reference work for professional personnel, researchers, and advanced stu-
dents. The chapters describe the changes in mental well-being that can occur with advanc-
ing age as a result of many influences: biological, social, and behavioral.
Mental health of the older population is a function of many aspects of modern society:
family life, caregivers, community and institutional care, ethnic and sociocultural dif-
ferences, and urbanization, among many other influences. The subject matter appears as
broad as the content of life itself; in fact, one might argue that mental health is about the
content and processes of life. If so, then the agenda for services, training, research, and
scholarship must be broad. In turn, the content of this volume is necessarily broad but also
reports in depth on the many facets of human life in the later adult years.
xx Preface
There is "regional intellectual" prosperity shown in the growth of many new specialty
journals. Since the first edition, an International Psychogeriatric Association has been
founded that organizes international meetings and publishes a journal, International Psy-
chogeriatrics. The American Psychological Association in the past decade began the
publication of Psychology and Aging, and many other new relevant journals are appear-
ing. Examples include the International Journal of Geriatric Psychiatry and Alzheimer's
Disease and Associated Disorders. This activity is healthy and promotes an air of opti-
mism about the future of the subject matter.
This Handbook assumes the task of keeping an integrated view of mental health. As we
learn more about difficult phenomena of aging (e.g., Alzheimer's Disease, behavioral
genetics, and memory), there is a tendency to split the subject matter into subspecialities
that have less intercommunication. This volume is intended to provide a place where all of
the pieces are fitted together, however provisionally. The editors have encouraged efforts
to consolidate information about mental health and aging during a time of furious expan-
sion of knowledge about brain, behavior, and well-being. They are grateful to the many
excellent authors for meeting this challenge.
We hope that this book will provide the background and motivation to stimulate future
research, scholarship, and services in this important area of human concern.
We are grateful to the Anna and Harry Borun Foundation for support of the senior
editor. We also gratefully acknowledge the work of Lisa Dieckmann, who undertook the
painstaking task of indexing this volume. Finally, we acknowledge the unfailing efforts of
Alieh Mehri Eslami and Emily Zoller; without their administrative expertise the present
volume would not have been possible.
Concepts and Issues in Mental
HeaHh and Aging
Barry D. Lebowitz and George Niederehe
I. Introduction
II. A Decade of Research Progress
III. A Bio-P&ycho-Social Perspective
IV. Concepts of Mental Health and Mental Illness
A. Norms and Abnormality
B. Controllability and the Labeling of Abnormality as a Disease
C. Positive Mental Health
V. Intellectual Underpinnings
A. Major Themes
B. Time Dimensions
C. Negative Age Stereotypes
VI. Future Research Issues
A. Likely Trends
B. Research Needs and Key Issues
VII. Service System Policy Dilemmas for the 1990s
A. Mental Health Service Use
B. Primary Care and Mental Health
C. Family Support and the Caregiver at Risk
D. Long-Term Care
E. Disability
F. Too Old, Too Sick
VIII. Education and the Need for Trained Personnel
IX. Conclusion
References
I. Introduction
In the ten years that have followed upon publication of the first edition of this Handbook,
the field of mental health and aging has undergone steady evolution, not the least of which
Handbook of Mental Health and Aging, Second Edition
Copyright © 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
4 Barry D. Lebowitz and George Niederehe
has stemmed from the continuing demographic growth and transformation in charac-
teristics of the generation of individuals now elderly. In terms of research, very significant
advances have been made in our capacity to characterize, understand, and treat mental
disorders among the aged. Changes in the mental health service system to improve care
for the elderly population have not, however, tended to keep pace with this overall record
of scientific progress.
In this chapter, our primary purpose is to provide an overview of the current status of
the field. As such, we break no new ground; rather, we synthesize and appraise an
accumulation of knowledge and experience from the recent decade of work in mental
health and aging. We also review a number of fundamental concepts, note various areas of
progress, and highlight particular issues of special or continuing importance for the field.
In doing so, we acknowledge the significant contribution of Birren and Renner (1980) in
the first edition of this Handbook. In many ways this chapter constitutes an update of that
earlier chapter, and the reader is referred to that document for its exposition of the
historical and conceptual background of the field.
Our scope in this chapter is broad rather than deep, and selective rather than en-
cyclopedic. We have attempted to address only a limited number of concerns for which
sufficient information has accumulated over the past decade to allow either a more precise
delineation of research questions or further specification of conclusions. Though our
selection of topics may thus represent a blueprint for consideration and potential action, as
with any blueprint, the outcomes to be anticipated from implementation remain highly
tentative and subject to influence from a variety of forces.
The mental disorders of late life are widespread and serious and have pervasive effects
on older persons and those who are close to them. In later chapters in this Handbook, the
full scope of these disorders will be presented. It is clear from examining the data in these
chapters on the prevalence and distribution of the mental disorders that much remains to
be learned about risk factors, predictors of treatment response, and the general burdens of
disability and dysfunction in the present cohorts of older persons as well as those to come
in the future. Nonetheless, these data also belie most of the typical cliches about mental
disorders in the elderly. Old age is not inevitably a period of successive losses—a view
that has led many to assume, falsely, that mental illness occurs with a disproportionately
high prevalence among the elderly. Nor is aging so characterized by a process of natural
selection or survival of the fittest that one can assume that mental illness is uncommonly
rare among the surviving elderly. Differences among age groups in prevalence rates
appear more likely to be reflective of cohort differences than they are of aging effects.
As will be addressed at greater depth in later chapters, however, accurate recognition of
the pervasiveness of late-life mental disorders needs to be matched with a corresponding
sense of their treatability, rather than viewed with therapeutic pessimism. Though research
is always needed to further specify the nature, applicability, and limitations of treatment,
over the past decade we have witnessed the emergence of a broad array of efficacious
pharmacologic, somatic, and psychotherapeutic strategies for treatment of late-life mental
disorders and management of associated symptoms. This broad therapeutic armamen-
tarium, now accessible to clinicians in a variety of settings and systems, represents one of
the great stories of success and accomplishment in the field, and the systematic and
cumulative body of knowledge underlying it deserves widespread recognition and applica-
tion.
1. Concepts and Issues 5
II. A Decade d Research Progress
The broad topic of mental health and aging extends to almost all areas of contemporary
research in the biological, clinical, behavioral, and psychosocial areas. This wide domain
is currently experiencing an excitement and a burst of scientific creativity not previously
seen; it promises to advance markedly our understanding of the field.
The past decade has seen mental health issues brought to the forefront of gerontological
and geriatric discussion and, conversely, has seen aging issues being examined by those in
the mental health field. These developments are made all the more striking when viewed
in the context of the tremendous gains in a number of areas of basic science such as
fundamental neuroscience, mechanisms of cognitive and intellectual function, and social
network theory.
Research progress in the last decade has been substantial. Using the latest approaches
and conceptualizations in basic neurobiology, scientists have identified the processes by
which nerve cells change to create pathology. In addition, using high-powered imaging
techniques, investigators have developed methods for directly studying the brain and for
linking functional abnormalities with structural lesions. Progress in understanding the
nature and progression of Alzheimer's disease has been particularly notable.
Research in epidemiology has highlighted the growing significance of age of onset.
Clinical research has identified features of depression and schizophrenia that can be used
to distinguish late-onset disease from that exhibited by patients who developed these
diseases earlier in life.
The approaches of psychoneuroimmunology have been used to demonstrate the mutual
reinforcement of psychosocial and neurobiological factors in morbidity and mortality.
This research has been instrumental in allowing us to move beyond the individual patient
and to highlight the consequences of long-term caregiving for the spouses and other
family members of patients with Alzheimer's disease and other chronic conditions.
Well-controlled clinical trials of pharmacologic, psychotherapeutic, and combined
treatments that have been launched in the last decade have resulted in the establishment of
validated treatment protocols in a number of major disorders. Longitudinal methods have
made possible increased attention to issues of clinical course and outcome of disease and
have demonstrated the need for continuation and maintenance treatment following the
acute treatment phase. Long-term symptom management has emerged as a major focus of
concern and, along with this, issues around appropriate systems of care and the need for
changes in the methods of payment and reimbursement have emerged as primary.
Thus, developments in basic science and clinical investigation are providing a firm
base for treatment and prevention of the major mental disorders among the aged. Direc-
tions for future research are clearly established. This rich body of scientific achievement
has developed a significant momentum with an ever-increasing pace of achievement and
development.
At the same time, important developments in methodology have provided the impetus
for creative and sophisticated theory building. These developments have made it possible
to make more precise characterizations and examine increasingly complex models of the
phenomena of interest in this field. In doing so, the artificial distinctions between disci-
plines have been pushed aside, and attention to the mutual reinforcement of biological,
clinical, behavioral, and psychosocial factors in mental health and mental illness has