The burden of caregiving has usually been described and measured in three ways, including the extent of the workload, the difficulty in performing caregiving, and the perceived impact of caregiving on the caregiver’s life. When looking at the perceived impact of caregiving, the emotional burden is considered along with the impact on resources (Montgomery, 2002). Review of the literature on family burden reveals a number of tools. Research is needed to identify their effectiveness across late-life psychiatric disorders. The Burden Scale may be particularly useful in designing more individualized, targeted interventions because it assesses three dimensions of burden. Objective burden assesses the perceived impact of caregiving on tangible aspects of the caregiver’s life. Subjective demand burden assesses the degree to which the caregiver perceives caregiving to be demanding. Subjective emotional demand assesses the emotional impact of caregiving on the caregiver (Montgomery, 2002).

Goals for family caregiver therapy are derived from the position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from AD (Lyketsos et al., 2006). Existing scientific evidence and clinical experience have evolved into a treatment model of therapeutic interventions for AD sufferers and their caregivers. Although recommendations were made to treat the needs of AD caregivers, they also address the treatment needs of those caring for elders with chronic and late-onset mental and somatic disorders. These goals include caregiver education, specific problem-solving skills, resource acquisition, long-range planning, emotional support, and respite.

Caregivers perceive the demands and burdens of caregiving differently throughout the caregiving trajectory and differently from each other. It is therefore important to understand current caregiver burden and tailor intervention strategies to address these needs. For caregivers experiencing objective burden, resource acquisition, respite, and long-range planning are most important. For caregivers experiencing subjective demand burden, caregiver education, specific problem-solving strategies, and emotional support are most critical. For caregivers experiencing subjective stress burden, a support group and individual or family psychotherapy may be most helpful (Montgomery, 2002). Evidence includes a study by Farran and associates (2004), which found that building caregiver skills with an information- and support-oriented group decreased caregiver depression.

Cohort Issues

Among the most important considerations for the APPN conducting psychotherapy with older adults is an understanding of cohort effects, or the impact of having been socialized in certain beliefs, attitudes, personality dimensions, and abilities in another era. For example, the current cohort of elders is different from the future cohort of baby boomers (Knight, 2004). The stigma of psychiatric disorders is a significant issue for the current cohort of older adults. This stigma is expressed in an emphasis on physical symptoms, less discussion of emotions, and a preference for primary care rather than specialized mental health care to discuss personal emotional issues. Although elders prefer primary care, these providers have not demonstrated the expertise in recognition of psychiatric disorders presented in terms of physical symptoms. The empowerment and education of older adults, their families, providers, and the public are required to overcome the barriers imposed by stigma (Miller, 2004; SAMHSA, 2005). Outreach and peer support groups can also be effective (Miller, 2004). Members of this cohort usually have fewer years of formal education, but they have a wealth of wisdom from life experience. Psychotherapy may therefore need to be more concrete by offering suggestions, asking about the elder’s past experiences to explain a current situation, avoiding jargon, incorporating the elder’s wisdom, and sharing the APPN’s insights (Knight, 2004). It is important to understand personal and societal history to comprehend the patient’s experience and frame of reference to be able to formulate a meaningful therapeutic relationship and goals.

Societal Issues

Ageism and bias have contributed to a historically pessimistic perspective on the effectiveness of psychotherapy with the elderly. Stigma is a collective and cohort issue. As more accurate information about aging has evolved and as psychotherapy approaches have developed, clinical psychotherapy practice and research have developed over the past 2 decades. This research is yielding an evidence base to support specific therapy approaches for psychiatric disorders in late adulthood and specific information about adapting psychotherapy approaches for older adults. There is a great need for more qualified, specially trained APPNs to provide mental health care, including psychotherapy, to older adults. Because the treatment response may vary according to the living situation and diagnosis of the older adult, there is a need for more time for psychotherapy sessions (Pinquart & Sorenson, 2001). Existing funding streams and service delivery models need to be adapted to meet the need for long-term, community-based treatment, housing, and support (SAMHSA, 2005). Organizational barriers such as therapy time, transportation, and available providers may not match the needs of the current cohort of elders. Of particular concern is the lack of coordination among agencies and providers in the treatment of late-life psychiatric disorders that are complicated by significant comorbidity issues (Jenkins & Laditha, 1998). APNs, certified in psychiatric-mental health or gerontology can make a significant contribution to the emerging elder mental health crisis.

Common Psychiatric Disorders

Challenges in assessing psychiatric symptoms in the elderly include the masking of symptoms by comorbid disorders and medication, difficulty in obtaining an accurate mental health history, age-related variation in symptom presentation, and denial of symptoms. The following sections provide an overview of the significant late-life psychiatric disorders, assessment strategies, goals for psychotherapy, and treatment considerations and efficacy for each of the following geriatric psychiatric disorders: mood disorders, anxiety, schizophrenia, and dementia. Web sites for resources and practice guidelines are included in Box 13-1.

Box 13-1 Web Sites for Geriatric Mental Health Resources and Practice Guidelines

www.POGOe.org: Portal of Geriatric Online Education (CornellCARES.com): geriatrics psychosocial patient handouts

www.alz.org/AboutAD/WhatisAD.asp

www.geronurseonline.org: Nurse Competence in Aging is a 5-year initiative funded by The Atlantic Philanthropies (U.S.) and awarded to the American Nurses Association (ANA) through the American Nurses Foundation (ANF). It represents a strategic alliance between ANA, the American Nurses Credentialing Center (ANCC), and the John A. Hartford Foundation Institute for Geriatric Nursing, New York University College of Nursing.

www.sydneyplus.ets.org: SydneyPLUS Knowledge Portal of ETS test collection

www.americangeriatrics.org/education/home_recommendations.shtml: The American Geriatrics Society (AGS) and the American Association for Geriatric Psychiatry (AAGP) have updated the 2003 Consensus Statement on Improving the Quality of Mental Health Care in U.S. Nursing Homes: Management of Depression and Behavioral Symptoms Associated with Dementia.

www.psych.org/psych_pract/treatg/pg/pg_dementia_32701.cfm: Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias of late life

www.aagponline.org: American Association for Geriatric Psychiatry information and resources about geriatric mental health practice

www2.uwsuper.edu/cee/lll/IIRLR/: International Institute for Reminiscence and Life Review

Depression

Depression, including subsyndromal depression, and other mood disorders are common among the elderly but are not a natural aspect of aging. Although rates of remission are comparable, rates of recurrence are greater for ages 65 to 79 years (Mueller et al., 2004). The Depression and Bipolar Support Alliance has indicated that mood disorders are under-recognized, inadequately treated, and under-serviced in older patients. Under-recognition is a particular problem in primary care, the health care setting most often used by the elderly. Diagnosis is confounded by overlapping symptoms of dementia or comorbid medical conditions, vague somatic complaints or nonclassic symptoms, time and staffing constraints, and the stigma of mood disorders. Doses, recovery rates, and clinicians’ expectations for treatment success are often too low (Charney et al., 2003).

Differences in symptoms of depression in the elderly and young adults include an emphasis on physical (e.g., aches, pains) and cognitive symptoms (e.g., memory), as well as changes in sleep, appetite, and use of pain medication. Psychologically, the elderly are more likely to express an exaggerated sense of helplessness, apathy, and emptiness or loneliness, rather than other emotions (Husain et al., 2005). They may also be quite irritable, masking the underlying sense of despair. Older adults tend to withdraw from their activities. Even though they talk less about suicide, elders have seven times the rate of completed suicides, especially older white males, compared with other groups (Shanmugham et al., 2005). Such differences must be addressed in assessment and psychotherapy interventions (Husain et al., 2005).

Assessment

Chapter 4 describes how to conduct a comprehensive history and psychiatric assessment. Specific assessment tools appropriate for the older adult are highlighted here. Different versions of the Geriatric Depression Scale (GDS) are widely used as a screening tool in practice. Given the prevalence of under-recognition, especially in primary care, efforts have been made to devise a quick, reliable, and valid screen such as the AB Clinician Depression Screen (ABCDS), which was derived from the GDS (Molloy et al., 2006). The Montgomery-Åsberg Depression Rating Scale (MADRS) can be used to measure symptom severity over time and the impact of psychotherapy, and it may be more appropriate than the Hamilton Depression Rating Scale (HAM-D) (1960) and Beck Depression Inventory (BDI), which have many somatic items (Linka et al., 2000). Hopelessness appears to be the factor most predictive of suicide and therefore should trigger an assessment of suicidal ideation (Szanto et al., 2001; Uncapher et al., 1998). The Mood Disorder Questionnaire (MDQ) is a 15-item scale to screen for bipolar disorder that is quick and easy to administer and score (Hirschfeld et al., 2000). The Cornell Scale for Depression in Dementia (CSDD) is the most widely used diagnostic scale for depression in dementia. The Young Mania Rating Scale (YMRS) is an 11-item scale used to assess the severity of mania (Young et al., 1978). Table 13-1 lists screening tools for mood disorders.

Table 13-1 Diagnostic and Screening Tools for Mood Disorders

Scale	Study
Geriatric Depression Scale (GDS)* (see Appendix I-16, p. 165)	Yesavage et al., 1982-1983
Beck Depression Inventory (BDI)*	Beck et al., 1961
Cornell Scale for Depression in Dementia (CSDD)^†	Alexopoulos et al., 1998
Hamilton Depression Rating Scale (HMD)^†	Hamilton, 1960
Montgomery-Åsberg Depression Rating Scale (MADRS)^†	Montgomery & Asberg, 1979
Mood Disorder Questionnaire (MDQ)^‡	Hirschfeld et al., 2000
Young Mania Rating Scale (YMRS)^§ (see Appendix I-17, p. 166)	Young et al., 1978

^* Self-report.

^† Observer rated.

^‡ Self-report or observer rated.

^§ Self-report and observer rated.

It is critical to differentiate depression from delirium and dementia. Depression or apathy with mild cognitive impairment often precedes dementia (Janzing et al., 1999). Delirium is an acute confusional state with changes in consciousness, attention, cognition, and perception that develops within hours or days and that tends to fluctuate over the course of the day. Delirium is usually reversible when the underlying somatic or iatrogenic cause is identified and treated. The onset and progression of depression is more rapid than that of dementia, although onset is more rapid in vascular than Alzheimer’s dementia (AD); memory may or may not be impaired. In depression, speech is more likely to be understood; cognitive losses and disabilities are emphasized; and performance on a mental status examination is inconsistent.

Goals

Because of age-related differences, the treatment foci in late-life depression must include symptom reduction to remission, adherence to the health care regimen, relapse recognition and prevention, reduction of the burden of functional disability, and enhancement of psychosocial factors and quality of life (Folks, 2003). Goals of psychotherapy are to understand illness, learn new or different coping skills and warning signals, and manage the illness or symptoms. Frequent therapy themes include grief, isolation, caretaking burden or stress, finding meaning in life, and balancing resources. As with all late-life psychiatric disorders, APNs need to consider working with the elder’s family.

Treatment

Psychotherapy is considered a viable treatment for elders (Landreville et al., 2001). CBT, reminiscence therapy (RT), brief PDT, and a combination of IPT and medication have the most evidentiary support for the treatment of mild to moderate major depression (Mackin & Arean, 2005). Results of randomized, controlled trials suggest that the combination of pharmacologic and psychotherapy interventions, especially IPT, may be more effective than either intervention alone in treating recurrent major depression (Alexopoulos et al., 2001; Bartels et al., 2003; Reynolds et al., 1999; Steffens, 2005). More research is needed on maintenance therapy, the treatment of subsyndromal depression, and special populations, including minorities and those with mid cognitive impairment (Mackin & Arean, 2005). It has been suggested that CBT and RT have the potential to prevent depression in elders who present with risk factors for depression, including bereavement, sleep disturbance, chronic disorders, prior depression, and female gender (Cole, 2005).

These treatment options can be delivered individually or in groups. Psychotherapy is especially useful in the older adults to avoid adverse events from medications and drug interactions. Medical comorbidities and cognitive impairment require adaptations and can negatively impact therapy effectiveness (Birrer & Vemuri, 2004; Lapid & Rummans, 2003). There is much promise in the results of large clinical trials of different models of depression care, including integrated treatment in primary care, enhanced referral, and depression care managers (DCMs). The outcomes of the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E), Improving Mood: Promoting Access to Collaborative Treatment for Late-Life Depression (IMPACT), and Prevention of Suicide in Primary Care Elders: Collaborative Trial (PROSPECT) trials may lead to more effective models of care (Oxman et al., 2005).

Bipolar Disorder

Although 5% to 19% of patients presenting to geriatric psychiatrists have bipolar disorder, there is a paucity of treatment outcome studies (Dunn & Rabins, 1996). Psychopathology can be severe and characterized by incomplete responses, further episodes, and high mortality (Young, 2005a). Bipolar mania in late life usually is milder than in younger patients; can present as mixed, dysphoric, or agitated states; and has a higher probability of irritability. Bipolar depression in late life usually manifests with depressed mood; sleep, appetite, and activity level disturbance; and, cognitive impairments, such as executive dysfunction that may mimic dementia (i.e., pseudo-dementia) (Young, 2005a). Primary bipolar disorder may be early onset (i.e., recurring in later years) or late onset (first episode at age ≥50 years). Older adults with secondary bipolar disorder may not have a family history of bipolar disorder, but secondary mania more commonly has a late onset resulting from neurologic disorders and other general medical conditions and from medication-induced mania.

Assessment

It has been well documented that bipolar disorder is underdiagnosed. The MDQ and YMRS can be used for a more thorough assessment if mood swings, mania, or depression is suspected (Box 13-1). Longitudinal assessment is especially important because depression is more prevalent than mania; depression often precedes mania; mania presents with paranoia, agitation, and delusions; and symptoms overlap with other psychotic and cognitive disorders (Sajatovic et al., 2005). Given the high rates of alcohol abuse and suicide among older adults with bipolar disorder, it is important to screen for both. Diagnostic challenges associated with bipolar disorder in older adults include patient underreporting, vague or nonclassic symptoms, comorbid health conditions, and the fact that depressive and manic symptoms can be induced by somatic conditions and medications.

Goals

Because bipolar disorder imposes significant risks and burden, psychotherapy goals must address treatment adherence; prevention of recurrence; prevention of excess disability in cognitive, behavioral, and global functioning; and decrease in mortality risk from cardiovascular disease, violence, and substance abuse. Treatment adherence is estimated to be 50% among bipolar patients (Charney et al., 2003).

Treatment

Treatment has primarily focused on medications, including mood stabilizers and atypical antipsychotics (Young, 2005b). There have been no controlled psychotherapy trials in geriatric bipolar disorder. There is some empirical support for IPT and CBT (Scott & Todd, 2002). Education of patients and caregivers about bipolar disorder, treatment adherence, health maintenance, and good sleep practices is recommended (Gildengers et al., 2005). Fielding and colleagues (1999) found that a nursing intervention program enhanced adherence. As with other late-life psychiatric disorders, mental health care, whether inpatient, outpatient, or emergency department, is used less than case management services (Depp et al., 2005).

Anxiety Disorders

Anxiety disorder prevalence data underestimate the clinical significance of subsyndromal anxiety states that require intervention and the fact that anxiety disorders are upstaged by major depressive disorder MDD if co-occurring (Flint, 2005). According to the report of the Surgeon General (1999), anxiety disorders are probably the most commonly occurring psychiatric disorders in the elderly. The overall community prevalence of anxiety disorders is estimated to be 11.4%. Generalized anxiety disorder (GAD) is estimated to have a prevalence of almost 17%. Phobias are the second most prevalent anxiety disorders, with rates of 7.3% for specific phobias, 4.1% for agoraphobia, and 1% for social phobia. The least prevalent anxiety disorders include obsessive-compulsive disorder at 1.5% and panic disorder at 0.5%. However, the prevalence of anxiety symptoms not meeting the threshold of a disorder is estimated to be between 17% and 21% in community samples and greater than 40% among chronically ill samples (Brenes et al., 2005; Mehta et al., 2003).

The incidence of PTSD in elderly persons is the same as or less than that of younger persons. However, it is thought that instruments and criteria for anxiety disorders have not been sufficiently validated in this population and that comorbid depression often obscures clarity about diagnosis of anxiety disorders (Wetherell et al., 2005a). Most research of PTSD in elderly persons has examined individuals who are Holocaust survivors or who were prisoners of war during World War II. In these populations, symptoms of PTSD tend to be chronic, persisting into late life in many cases. In one study, spouses of those who had suffered more traumatic experiences and PTSD symptoms in World War II also had more PTSD symptoms (Bramson et al., 2002). This study speaks to the importance of family work and a systems approach for treatment if one partner has suffered significant trauma.

Some anxiety disorders are more likely to occur during late adulthood. These include GAD, agoraphobia, anxious depression, and anxiety associated with medical illnesses. Major depression with associated anxiety is common in older adults (Beekman et al., 2000). Anxiety usually has an earlier onset. Although treatable, it may be difficult because of greater severity and higher suicidality, yielding poorer outcomes (van Hout et al., 2004). Obsessive-compulsive disorder and panic disorder usually have much earlier onset and tend to be more severe and disabling. There are several risk factors for geriatric anxiety, including gender (female), urban living, history of worrying, poor physical health, low socioeconomic status, high-stress life events, depression, and alcoholism.

Somatic symptoms, such as dyspnea, dizziness, chest pain, irritable bowel, heartburn, tremors, initial insomnia, and hypochondriasis, are predominant in older adults experiencing anxiety disorders. Anxiety disorders may also be expressed as irritability, nervousness, trouble concentrating, worry, and fear. It may be difficult to determine whether the symptoms reflect anxiety or an underlying physical cause, such as endocrine imbalance, pulmonary disease, delirium or dementia, or medication side effects or interactions (Burke et al., 2004; Flint, 2005).

Assessment

The Clinical Anxiety Scale (CAS) is a 6-item scale derived from the Hamilton Anxiety Scale, deleting items that overlap with depression. It is used as a screening tool and as a measure of severity over time, especially with persons not diagnosed with an anxiety disorder. The Penn State Worry Questionnaire (PSWQ) is a 16-item inventory that is reliable with older adults and used to measure pathologic worry, which is central to GAD. An 8-item version has also been used with older adults. It can be used to measure impact of psychotherapy (Hopko et al., 2003). There is some support that the coexistence of worry and symptoms is more significant than duration (Stein, 2004). FEAR (i.e., frequency of anxiety, enduring nature of anxiety, alcohol or sedative use, restlessness or fidgeting) is a 4-item version of the ADS GA (i.e., anxiety disorder scale–generalized anxiety subscale) for use in primary care (Krasucki et al., 2005). Table 13-2 lists the diagnostic and screening tools for anxiety.

Table 13-2 Diagnostic and screening tools for anxiety disorders

Scale	Study
Hamilton Anxiety Rating Scale (HAM-A)* (see Appendix I-18, p.168)	Hamilton, 1959
Clinical Anxiety Scale (CAS)	Westhuis & Thyer, 1989
Penn State Worry Questionnaire (PSWQ)^†	Hopko et al., 2003
FEAR*	Krasucki et al., 1999

^* Observer rated.

^† Self-report.

Goals

Treatment goals include rapid management of acute anxiety, clinically meaningful symptom improvement, remission and functional recovery, significant increase in quality of life, significant reduction in inappropriate use of primary care, and relapse prevention (Goodman, 2005). Because anxiety commonly manifests somatically in older adults and pharmacologic relief takes time, it is imperative to make concrete suggestions for the management of acute anxiety. Given the prevalence of GAD, the specific worries of the older adult patient must be a focus of psychotherapy.

Treatment

The research support for the use of many interventions for anxiety in the elderly is not as robust as for depression, but based on success in other populations, these interventions may be effective. Behavioral therapy has been used to confront fears and promote habituation through desensitization. Anxiety symptom management has used relaxation training and biofeedback. Supportive individual and group therapy has involved encouragement, listening, reassurance, redirection, and connections. Cognitive restructuring, interpersonal psychotherapy, and psychoeducation have also been used in the treatment of anxiety disorders (Burke et al., 2004).

Wetherell and colleagues (2005a) conducted a review of evidence-based treatment of geriatric anxiety disorders. The results of this review recognized the potential value of CBT and pharmacologic treatments for late-life anxiety disorders, especially GAD. CBT has had a positive response, although lower than for younger adults. Response to pharmacologic treatment seems more robust. Promising practices include CBT enhancements to counteract cognitive changes, attention to quality of life indicators, cognitive limitations as predictors of response, treatment in primary care settings, and CBT based on intolerance of uncertainty. Limitations include samples and settings, a predominant focus on GAD and use of group interventions, and the lack of knowledge about long-term maintenance of treatment effects. Given elders’ preference for primary care settings, the modular intervention for anxiety in older primary care patients offers hope for future treatment (Wetherell et al., 2005b).

Schizophrenia

Elders with early-onset schizophrenia have had a debilitating chronic disorder most of their lives. The course of the disorder is relatively stable, with some changes in symptom intensity; positive symptoms become less prominent, whereas negative symptoms persist. Severity of movement disorders in older patients is greater than in younger patients. Cognitive decline is similar in patients regardless of age, age of onset, or illness duration (Heaton et al., 1994). Depressive symptoms are common in chronic schizophrenia and are linked to physical, social, and financial distress. Demoralization and relapse are also associated with the clinical symptoms of depression. Depression may be a core symptom cluster, by-product of severe psychosis, or independent symptom (Kasckow et al., 2001).

Late-onset schizophrenia occurs after the age of 45 years and accounts for 20% to 25% of elders with schizophrenia. It differs from early-onset disease in that it is more common in women, is mostly a paranoid subtype, and has less severe symptoms, including less severe negative symptoms, less impairment in learning and abstraction or cognitive flexibility, and less affective blunting or personality deterioration, thereby requiring lower doses of antipsychotics (Rabins & Lavrisha, 2003). Up to 20% of elderly patients with schizophrenia may maintain remission (Jeste & Twamley, 2003).

Assessment

Assessment should address the full range of schizophrenia symptom clusters, including presence and severity of psychosis and psychotic-related symptoms, positive and negative symptoms, depression, cognitive changes associated with the negative symptoms, and neurocognitive impairment. Given the widespread use of older antipsychotic medication in this cohort and an increased prevalence of tardive dyskinesia with age, it is important to assess for involuntary movement side effects with the Abnormal Involuntary Movement Scale (AIMS) (Lowery et al., 2003). Table 13-3 lists the diagnostic and screening tools for schizophrenia.

Table 13-3 Diagnostic and Screening Tools for Schizophrenia

Scale	Study
Brief Psychiatric Rating Scale (BPRS)*	Overall & Gorham, 1962
Positive and Negative Syndromes of Schizophrenia (PANSS)^†	Kay et al., 1987
Abnormal Involuntary Movement Scale (AIMS)^‡	Guy,1926