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Working with Older Adults: Misconceptions

Working with Older Adults: Misconceptions

Working with older adults can be very meaningful and rewarding. However, misconceptions about mental health and older adults are abundant. These misconceptions may contribute to the lack of trained geriatric mental health professionals, and in turn, a lack of trust in mental health services by older adults. In this post, I would like to address some of these misconceptions and provide both research evidence and clinical experience to dispel them.  

Misconception #1: Most older adults are depressed.

This is a common misconception, even among clinicians. In Gregory Hinrichson’s book, Assessment and Treatment of Older Adults: A Guide for Mental Health Professionals he notes “in my experience, mental health practitioners routinely guess that 30% to 50% of community-residing older adults are seriously depressed” (page 59). The reality is that the incidence is much lower, and the prevalence of mental health diagnoses decreases with age (except for dementia). In a study by Gum, King-Kallimanis, and Kohn (2009), the prevalence of anxiety disorders was 20.7% in adults 18-44 years-old, 18.7% in adults 45-64 years-old, and 7.0% in adults 65 years of age and older. Similar results were found with mood and substance use disorders. Overall, the authors reported the prevalence for any disorder was 27.6% in adults 18-44 years-old, 22.4% in adults 44-64 years-old, and just 8.5% in adults 65 years of age and older. A more recent study by Reynolds et al. (2015) observed similar results, noting an overall pattern of decreasing rates of mood, anxiety, substance use, and personality disorders with increasing age. They noted one reason for this pattern could be explained by the socioemotional selectivity theory (Carstensen, Isaacowitz, & Charles, 1999). This theory states that older adults adopt a limited perception of time and a present-focused state of awareness, seek the fulfillment of meaningful goals, and select the company of familiar social partners, all which decrease the likelihood that stressful situations will occur and increase the likelihood of experiencing positive emotions. There are additional theories to explain this trend, but the bottom line is that this trend has been observed again and again. We are not doomed to be depressed, and assuming all older adults are depressed can lull us into believing that it is “normal,” subsequently not indicating a need for intervention. 

Misconception #2: Older adults would rather take medicine than engage in psychotherapy. 

Multiple studies indicate just the opposite. In a study by Raue et al. (2017), the authors note that older adults prefer psychotherapy over medication to treat their depression, but rarely receive it due to access, availability, clinician workforce limitations, and individual-level factors like stigma. Adding to this, only about 44% of older adults respond and a third achieve remission with a single agent antidepressant, rates lower than that for middle-aged adults (Nelson et al., 2008). Additionally, drug interactions and side effects are often more pronounced in older adults. This study also notes medication adherence issues with older adults, which can be compounded by the fact that older adults often receive mental health treatment in a primary care setting alone. In my own practice, I see direct evidence in contrast to this misconception. Only a small fraction of my older adult clients take antidepressant medication (for depression and/or anxiety). The most common concern of my clients is side effects. Another issue I hear is stigma, feeling like something is “really wrong” if they need to “resort to” medication. I tend to refer to psychiatry when vegetative symptoms are preventing psychotherapeutic gains and prefer psychiatry over primary care for closer monitoring and regular discussions about when to taper. Bottom line: Older adults are generally not excited about taking (more) medications, and respond to medications differently than younger adults. Their wariness is understandable. 

Misconception #3: Older adults are resistant to making changes. 

First of all, if all older adults were resistant to making changes, I would be seriously burned out by now. I see highly motivated individuals in therapy, across all age groups. If older adults were resistant to making changes, we would also not be seeing the increasing numbers of outcome studies about the effectiveness of psychotherapy in older adults. Behavior therapy, cognitive-behavior therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, reminiscence therapy, and interpersonal therapy have all been identified as effective with older adults. Raue et al.’s study also highlights that many new psychotherapy approaches specifically for depression also target depression in the context of comorbid chronic conditions such as chronic obstructive pulmonary disorder (COPD), arthritis, diabetes, heart failure, and Parkinson’s Disease as well as acute medical conditions such as falls, neurological conditions, and cardiovascular events. That said, psychotherapy with older adults, particularly with medical conditions, is not simply the same treatment as that with younger adults. The protocols for these treatments have been modified and tailored to the needs of older adults and their levels of functioning. When I first began working with older adults as an intern with the Veterans Health Administration, I know I came across as quite off-putting to many older clients with all my handouts (with tiny font), quick pacing, and extensive homework expectations. With the guidance of my incredible supervisors, I learned to change the pace of therapy with my older clients, spend more time rapport-building and hearing their stories, and moving at a pace that worked with the individual client based on their medical and cognitive abilities. I also learned not to introduce too much in a session, and allocate more time to focus on a particular skill or concept. Of course, we want to tailor psychotherapy to all our clients, whatever their ages. There are some very helpful resources out there (Hinrichson’s book!) that can help guide providers to modifications for older adults specifically. 

Misconception #4: Cognitive impairment makes psychotherapy useless. 

Not true! There are many studies which demonstrate otherwise. In a review of community-based interventions to improve depression, anxiety, and adjustment (Regan & Varanelli, 2013), several studies demonstrated positive findings in the treatment of depression in older adults with mild cognitive impairment (MCI) or early dementia using problem-solving and modified cognitive behavior therapy approaches. Tonga et al. (2021) evaluated the feasibility and effectiveness of a psychosocial intervention consisting of cognitive behavioral therapy, cognitive rehabilitation, and reminiscence for people with mild cognitive impairment (MCI) or dementia and concluded it was effective at reducing depressive symptoms. During my tenure at the VA, I had the fortune of being trained in Problem-Solving Therapy (PST). As part of this extensive training, pre and post data were collected from the veterans on the efficacy of PST. Every veteran I implemented PST with during training and data collection was diagnosed with some level of cognitive impairment. Although this rollout was not specifically designed to address cognitive impairment, it was not an exclusion factor. It proved to be a highly effective treatment with this older adult population (Beaudreau et al. 2018). In my practice now, I see many clients diagnosed with Mild Neurocognitive Disorder, and have seen improvements in both mood and cognitive symptoms as a result of treatment. 

These are just a handful of the misconceptions surrounding older adults and mental health. In my previous post about mental health training in geriatrics (https://www.ce-credit.com/blog/working-with-older-adults-room-to-improve), I noted that it is not surprising that many older adults have bad experiences with health care providers given the lack of provider education and experience. On the other hand, with these misconceptions about older adults, it is no wonder providers may avoid working with older adults. Thankfully, there are many researchers and educators addressing these misconceptions. Hopefully over time we can continue to bridge the training gap and meet the needs of this very special population. 

For more information about aging facts versus fiction, see https://www.apa.org/pi/aging/resources/guides/myth-reality.pdf

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References: 

Beaudreau, S. A., Karel, M. J., Funderburk, J. S., Nezu, A. M., Nezu, C. M., Aspnes, A., & Wetherell, J. L. (2022). Problem-solving training for Veterans in home based primary care: an evaluation of intervention effectiveness. International psychogeriatrics, 34(2), 165–176. https://doi.org/10.1017/S104161022000397X

Carstensen, L.L., Isaacowitz, D.M., & Charles, S.T. (1999) Taking time seriously. A theory of socioemotional selectivity. American Psychologist, 54(3), 165-168. https://doi.org/10.1037/0003-066X.54.3.165

Gum, A.M., King-Kallimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication. American Journal of Geriatric Psychiatry, 17, 769-781. https://doi.org/10.1097/JGP.0b013e3181ad4f5a

Hinrichson, G.A. (2020). Assessment and Treatment of Older Adults: A Guide for Mental Health Professionals, American Psychological Association. http://dx.doi.org/10.1037/0000146-000

Nelson J, C., Delucchi,  K., & Schneider, L,S. (2008) Efficacy of second generation antidepressants in late-life depression: a meta-analysis of the evidence. American Journal of Geriatric Psychiatry, 16(7), 558-567. doi: https://doi.org/10.1097/01.JGP.0000308883.64832.ed

Raue, P.J., McGovern, A.R., Kiosses, D.N., & Sirey, J. (2017). Advances in psychotherapy for depressed older adults. Current Psychiatry, 19(9). doi:10.1007/s11920-017-0812-8

Regan, B., & Varanelli, L. (2013). Adjustment, depression, and anxiety in mild cognitive impairment and early dementia: a systematic review of psychological intervention studies. International psychogeriatrics, 25(12), 1963–1984. https://doi.org/10.1017/S104161021300152X

Reynolds, K., Pietrzak, R.H., El-Gabalawy, R., Mackenzie, C.S., & Sareen, J. (2015). Prevalence of psychiatric disorders in U.S. older adults: findings from a nationally representative survey. World Psychiatry, 14 (1), 74-81. https://doi.org/10.1002/wps.20193

Tonga, J. B., Šaltytė Benth, J., Arnevik, E. A., Werheid, K., Korsnes, M. S., & Ulstein, I. D. (2021). Managing depressive symptoms in people with mild cognitive impairment and mild dementia with a multicomponent psychotherapy intervention: a randomized controlled trial. International psychogeriatrics, 33(3), 217–231. https://doi.org/10.1017/S1041610220000216

Elizabeth Mosco, Ph.D., PMH-C, CPLC

Elizabeth Mosco, Ph.D. is a licensed psychologist in Reno, NV. She opened a private practice after 10 years of conducting home-based assessment and therapy with the VA Sierra Nevada Health Care System. Dr. Mosco’s clinical interests include maternal mental health, older adults, and third wave cognitive behavioral therapies.

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Opinions and viewpoints expressed in this article are the author's, and do not necessarily reflect those of CE Learning Systems.

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