Older adults experience a number of stressful events that may trigger or exacerbate mental disorders. Declining health, death of loved ones, loneliness, and moves away from home are all stressors that may impact mental health.1 It is estimated that as much as 20 percent of the adult population over the age of 55 experiences some form of mental illness.2 Along with early-onset disorders such as schizophrenia and major affective disorders that continue to affect people as they age, late-onset illnesses such as anxiety disorders, clinical depression, and dementia are prevalent in the aging population.2 Additionally, researchers are also now realizing the pervasiveness of substance (alcohol and prescription drug) misuse and abuse among older adults.
All of these mental health conditions can have a major negative impact on the functioning of older persons. Additionally, they can create barriers to the adoption of behaviors aimed at promoting physical health and can lead to additional health problems through their effect on self care and compliance with medication regimes.
The Institute of Medicine (IOM) has developed a conceptual framework for the prevention of, and early intervention for, mental disorders. This framework categorizes preventive interventions as universal, selective, and indicated.3
"Universal preventive interventions are targeted to the general public or a whole population group that has not been identified on the basis of individual risk . Selective preventive interventions for mental disorders are targeted to individuals or a subgroup of the population whose risk of developing mental disorders is significantly higher than average . Indicated preventive interventions for mental disorders are targeted to high risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental disorder, or biological markers indicating predisposition for mental disorder, but who do not meet DSM diagnostic levels . Indicated preventive interventions are often referred to as early intervention or an early form of treatment."3
This conceptual framework can be applied to activities that address all types of mental disorders from depression to substance abuse. However, more research is needed to increase our understanding of modifiable and protective factors for the development of mental disorders in late life. The IOM review of intervention research programs noted that most prevention programs in the area of mental health are directed at children and adolescents, and that there is a striking absence of prevention research programs targeted to the mental health needs of adults, including the elderly.4
According to the AoA, efforts to prevent mental disorders among older adults have been inadequate, and there is currently no national agenda to promote mental health and prevent mental disorders. Existing federal activities to address mental disorders and substance abuse among older persons are generally focused on the diagnosis and treatment of illness rather than early identification of those at highest risk or the implementation of preventive measures and mental health promotion activities.1
There is research indicating successful activities that can be undertaken to decrease depression, increase information processing, enhance self-efficacy in the performance of mental tasks, and improve memory. In particular, regular physical activity has been shown to have a positive effect on mild depression.5 However, the IOM report noted that the base of knowledge about prevention for some mental disorders is considerably more advanced than for others, particularly for depression.3
Comprehensive mental health promoting programs ideally consider the mental, physical, and spiritual well-being of the individual and provide opportunities to increase self-efficacy in a supportive environment. The goal of comprehensive mental health programs has been "to help older adults find pleasure and meaning in their lives, use appropriate supports, and retain or assume as much control over their lives as possible."6 Such programs are more likely to generate interest and participation among older persons. As one aging service provider noted, "If we schedule a session on depression, no one will come. But if we have a session on 'Making the Most of Your Life,' many will join--and we can talk about depression as an obstacle to overcome."7
The remainder of this section highlights recent federally sponsored research and activities aimed at maintaining the mental functioning of older persons or preventing its decline. The majority of the activities listed below were designed for individuals who were already at least somewhat impaired, rather than for healthy individuals interested in maintaining and/or enhancing their mental functioning. Table B provides a list of these programs and their principal sponsors. See Appendix B for specific information on each program.
|TABLE B. Programs and Activities Aimed at Maintaining the Mental Functioning of Older Persons or Preventing Its Decline|
|Older Adults and Mental Health: Issues and Opportunities||AoA|
|NIA Behavioral and Social Research Program||NIA|
|Alzheimer's Disease Anti-Inflammatory Prevention Trial (ADAPT)||NIA|
|Moderate Exercise Program for Older Women Caregivers||NIA|
|SAMHSA Mental Health and Aging Activities||SAMHSA|
|SAMHSA and National Council on Aging (NCOA) Joint Project||SAMHSA and NCOA|
|Substance Abuse Prevention and Treatment Block Grant (SAPTBG) Program||SAMHSA|
|Treatment Improvement Protocol (TIP) on Substance Abuse||SAMHSA|
|Community-Initiated Prevention Intervention Program||SAMHSA|
A review of these activities raises a number of questions for discussion at the TAG meeting, some related to the prevention of mental disorders and others to the special health promotion needs of persons with a range of mental disorders:
What are the major gaps in the literature on the prevention of mental disorders among the elderly?
What is the most effective role for caregivers, community programs, and public health professionals in preventing mental disorders?
What modifications are needed to ensure that existing health promotion and disease prevention activities will be effective for people with cognitive disabilities, substance abuse problems, or mental illness?
What additional research, data collection, and evaluation activities are needed in this area?
Are health promotion and disease prevention programs for individuals with cognitive disabilities, substance abuse problems, or mental illness effectively targeted to subgroups of older Americans in the settings where they reside?
What gaps exist in research, data collection, and program evaluation to assess mental functioning in old age in order to identify those at risk for further decline and to identify those who might benefit from treatment?