Mental health and the aging population: implications for rehabilitation counselors. (Mental Health and Aging).

The population of the United States is aging, and with this change in the composition of the population will come new opportunities and new challenges for rehabilitation counselors. In their "Profile of Older Americans," the Administration on Aging (2000) reported that there were over 35 million individuals, or 12.8% of the population, who were 65 years of age and older. This number is projected to increase to over 53 million, or 16.4% of the population, by 2020. By 2030, it is estimated that there will be over 70 million individuals 65-years-old and older, representing 20.1% of the population (Administration on Aging, 2000).

A confluence of social and economic factors, including economic instability and an increase in the retirement age, has resulted in extended involvement of older Americans in the workforce (Beatty & Burroughs, 1999; Finnerty-Fried, Barry, & Myers, 1986; Herr & Cramer, 1996). Kadlec (2002) reported that the number of older workers has been increasing steadily since the beginning of the 1990s, and now 95% of individuals between the ages of 55 and 64 who are still working plan to find another job after retirement. In the past year, the number of workers aged 55 or older jumped 8% to 20 million (Kadlec).

The growing size of the older population has also meant a steady growth in the number of older persons with disabilities (Calkins, Boult, Wagner, & Pacala, 1999; Koch & Rumrill, 1997). Almost 75% of the elderly (age 65 and over) have at least one chronic illness and about 50% have at least two chronic illnesses (Calkins et al., 1999). The number of Americans who will experience functional disability due to arthritis, stroke, diabetes, coronary artery disease, cancer, or cognitive impairment is expected to increase at least 300% by 2049 (Boult, Altmann, Gilbertson, Yu, & Kane, 1996).

These trends toward increased labor force participation and increased disability among older Americans will translate into more opportunities for rehabilitation counselors to serve older consumers. Based on their comprehensive training in case management, disability, and employment issues, rehabilitation counselors have a combination of knowledge and skills that enable them to effectively address the needs of older adults (Finnerty-Fried et al., 1986). However, rehabilitation counselors often do not have the direct experience needed to work with and accommodate the needs of older persons (Finnerty-Fried, 1985). Specifically, barriers for rehabilitation counselors working with the older population include (a) a lack of information on aging, (b) personal fear of aging, and (c) limited involvement with older adults (Bearden & Head, 1986). One reason for this limited involvement with older consumers is that the traditional vocational rehabilitation consumer is under 60 years of age. Clearly, however, rehabilitation counselors across settings will increasingly serve a greater number of people beyond the historically accepted "working age" of 15 to 64 (Beatty & Burroughs, 1999).

Bearden and Head (1986) examined the relationships between the three barriers listed above among counselors working in private rehabilitation facilities in Alabama. They found that an increase in information on aging was associated with less fear; however, they did not find a significant relationship between greater involvement with older persons and a lessening of the fear of aging. They concluded that one way to assist rehabilitation counselors in successfully working with older consumers was to provide training and information about aging, particularly to distill the myths and negative attitudes associated with the aging process.

A particularly important component in the rehabilitation counselor's ability to most effectively serve older individuals is an understanding of the significant impact of mental health and mental functioning on employment-related and general functioning. Due to the prevalence of mental health disorders among older Americans and the potential impact of these disorders on function and rehabilitation, it is vital that rehabilitation counselors are prepared to recognize and deal with mental health problems.

In a review of the human resource development literature over the last decade, Beatty and Burroughs (1999) identified several competencies that career development counselors and other professionals in the area of human resource development should possess when working with older workers. These included an understanding of: (a) the relationship between age and intelligence in working effectively with members of the aging workforce, (b) changes in cognitive development throughout adulthood, and (c) the relationship between age, work, and mental health. As the population ages and caseloads increasingly reflect this change, such understanding will become essential for rehabilitation counselors. The purpose of this article is to contribute to rehabilitation counselors' knowledge and understanding of the interaction between mental health and aging, with a focus on age-related changes in cognitive function, and the prevalence and impact of depression and anxiety.

Mental Health, Mental Illness, and Aging: The Scope of the Problem

Mental illness, particularly depression and anxiety, is a significant problem for adults 65-years-old and older. Nussbaum (1998) reported prevalence rates of mental illness among older adults at 12.3% for individuals living in the community, 70% for residents of nursing homes, and 50% for individuals in acute-care hospitals. The Surgeon General (1999) reported prevalence rates of the following mental disorders for individuals aged 55 and older: (a) 11.4% for any anxiety disorder, (b) 4.4% for any mood disorder, (c) 0.6% for schizophrenia, (d) 6.6% for severe cognitive impairment, and (e) 19.8% for any mental illness.

Numerous studies have reported a relationship between mental health and physical health among the older population. For example, Pinquart (2001) found a strong positive association of subjective health with physical health, functional health, and mental health. In this meta-analysis, higher levels of self-rated health representing an individual's overall sense of well-being were correlated with lower levels of depression. Hanks and Lichtenberg (1996) collected archival data from 812 consecutive admissions to a geriatric rehabilitation facility, including the index of comorbidity and the Geriatric Depression Scale. They demonstrated that "depression was related to cormorbid illness" (p. 788) and that this finding "is consistent with the link between depression and medical illness in the elderly." Aiken (1996) reported that studies of individuals aged 70-90 found that there is a higher correlation between health and intelligence than between age and intelligence.

Comorbidity has been defined as the coexistence of two or more conditions, one of which is a mental illness (Grilly, 2002). According to Borson, Bartels, Colenda, Gottlieb, and Meyers (2001), comorbidity can be considered the norm among the elderly population with mental disorders. Comorbidity of medical problems with mental health issues in the elderly population can be attributed to a number of precipitating factors. These factors can include (a) multiple personal losses, (b) chronic insomnia, (c) risk factors of heart disease and stroke, (d) neurodegenerative diseases, (e) progressive reduction in the number of social supports, and (f) limited access to adequate treatment (Reynolds, Alexopoulos, Katz, & Lebowitz, 2001).

Concerning limited access to mental health services, there is evidence that older adults are significantly underserved in the mental health service arena. Although people over the age of 65 comprise approximately 12.8% of the population (Administration on Aging, 2000), older adults are only using about 2% of private mental health services, between 4 and 7% of community mental health services, and approximately 9% of inpatient psychiatric services (Robb, Chen, & Haley, 2002).

Furthermore, the treatment of mental illnesses frequently occurs under the care of the individual's primary health care provider, rather than via a mental health specialist (Reynolds et al., 2001). One of the reasons cited for this phenomenon is that older adults often interpret their mental health symptoms as medical problems, resulting in greater utilization of physical health care services and decreased use of mental health services (Bravo & Silverman, 2001). The main problem with this trend is that both the recognition and the treatment of mental illness tends to be inadequate in primary health care settings (Reynolds et al., 2001). Borson et al. (2001) also reported problems with the treatment quality of prevalent mental health issues for elderly populations in both mental health and general health care settings.

Clearly the prevalence and impact of mental disorders among the elderly make knowledge and awareness of mental health a priority for rehabilitation counselors who serve older adults. The prevalence among older Americans of mental health disorders and the high level of comorbidity with physical disability underscore the importance of rehabilitation counselors' awareness of the risk factors, signs, and symptoms of mental illness. Also, in addition to increased awareness and vigilance when working with older consumers, it may increasingly fall upon rehabilitation counselors to help guide older consumers toward the most appropriate treatment. To help counselors achieve a better understanding of the complex mental health issues involved in serving older consumers, the remainder of this article will focus on three areas of mental health that are particularly prevalent among older persons. The areas to be addressed are: (a) cognitive functioning, (b) depression, and (c) anxiety disorders. The final section will underscore the relationship between these issues and rehabilitation counseling.

Cognitive Functioning

There is not currently a consensus about what types of changes in cognition and intellectual functioning constitute "normal" aging. Biologically, as the human brain ages, there are structural losses in neurons and the connections between them. Behaviorally, this can be seen as a decrease in working memory, attention to relevant information, and the speed of processing information (Li, 2002). Wedding and Cody (1990) reported that cognitive functions, in the absence of disease, tend to remain relatively stable up to about the age of 60. After age 60 there is a typical pattern of cognitive decline in those tasks that require mental flexibility and the ability to process information rapidly in novel situations. The results of both longitudinal and cross-sectional studies reveal substantial declines in mental abilities as one reaches age 70 and beyond (Aiken, 1996).

A contradicting opinion, however, was offered by Berg, Nilsson, and Svanborg (1988). They suggested that the idea that there is a general decrement in intelligence and memory in old age has been tenaciously held despite the existence of research findings to the contrary, and that the picture of declining intelligence with age has not been corroborated in longitudinal and sequential investigations. According to Herr and Cramer (1996), "the fact is that, in general, for most older workers, intellectual functioning is not impaired. Whenever health has been preserved, verbal scores have remained relatively stable" (p. 544). Herr and Cramer go on to point out, however, that "when extreme old age is considered, the general trend in cognitive function is downhill" (p. 544).

The relative consensus is that cognitive decline is generally an expected and natural consequence of the aging process. However, Aiken (1996) suggested that there is evidence that indicates declines in intellectual abilities during older adulthood are not inevitable, "except perhaps for people with cardiovascular disorders and certain other health problems or people living in deprived environments" (p. 286). Clearly, a number of variables are important predictors in the relationship between aging and cognition, primary among these are health and environment. Diamond (1993) highlighted the importance of an enriched environment to cognitive function. He stated "at every age studied we have shown anatomical effects [increase in frontal lobe and general brain mass and activity] due to enrichment and impoverishment. The results ... provide a degree of optimism about the potential of the brain of the elderly" (p. 212).

Depression

Depression is a serious, and sometimes life-threatening, mental health issue among the older population (Lelita, Palumbo, & Hanley, 2001). Nussbaum (1998) reported that the prevalence of major depression is between 2% and 8% for older persons living in the community (depending on the method of calculation). This prevalence rate increases to 10% for older persons in primary health care settings and 15% for older individuals in acute care or nursing home settings. The prevalence rate of clinical depression among elderly medical inpatients has consistently ranged between 18% and 40% (Nussbaum). Hayes (1997) reported that about one in 10 people aged 65 or older has clinical depression.

In old age, depression often follows a chronic and/or relapsing course. This course can be related to comorbidity with a medical illness, cognitive impairment, or the decrease or depletion of social supports (Reynolds et al., 2001). For example, Haynie, Berg, Johansson, Gatz, and Zarit (2001) listed risk factors for depression as decreased physical health, increased disability, and greater social isolation. It has been shown that depression is a risk factor for physical disabilities. Kivelae and Pahkala (2001) reported that depression often leads to increased disability status and negative outcomes of rehabilitation with individuals with stroke, myocardial infarction, chronic obstructive pulmonary disease, and hip fractures. They also point out that improvement in depressed mood is related to decreased physical limitations from chronic illness or disease. Lelita et al. (2001) stated that depression has been linked to longer hospital stays, decreased cognitive functioning, and negative medical outcomes.

deBeurs et al. (2001) analyzed factors related to the vulnerability of health and functioning in later life and reported that self-perceived poor health was a better predictor of mental health problems than the actual presence of chronic disease. Also, a sense of meaninglessness is often associated with depression. Conversely, a sense of meaningfulness is connected to increases in general psychological happiness, including satisfaction with life, higher self-esteem, and an absence of negative emotions (Takkinen & Ruoppila, 2001).

Even though it has been shown that depression has a significant impact on disability and physical functioning, it is too often viewed as the "normal" course of aging rather than a serious mental health issue that needs to be addressed (Hyman, 2001; Lelita et al., 2001). This is due, in large part, to the misconception that symptoms of decreased activity level, greater social isolation, and problems sleeping are associated with the aging process instead of an underlying depressive episode. This misinterpretation of depressive symptoms may be further complicated by an inclination to deny depression and instead report related feelings, such as frustration, worry, or irritability (Lelita et al., 2001).

Depression has also been linked to decreases in an older person's quality of life (Lelita et al., 2001), and these effects on quality of life can be significant (Scogin et al., 2001). These individuals may experience more family stress, increased social withdrawal, and more problems on the job (Lelita et al., 2001). As older adults become more depressed, their perceived health decreases, their ability to function and sense of mastery diminishes, and perceived contentment declines (Badger, 2001).

Vaillant and Mukamal (2001) studied 237 college students and 332 inner-city youth for 60 years or until death to analyze "good" and "bad" aging. They found that "good" and "bad" aging from age 70-80 could be predicted by factors present before the individuals were 50-years-old. They examined 13 predictor variables that were evaluated before the men turned 50-years-old, including (a) smoking, (b) alcohol abuse, (c) body mass index, (d) years of education, (e) some regular exercise, (f) stable marriage, (g) maturity of defenses, (h) depression, (i) parental social class, (j) warmth of childhood, (k) ancestral longevity, (1) stable childhood temperament, and (m) objective disability. The results of this longitudinal study were that, when controlling for plausible extraneous variables, depression was the only predictor variable that was related to the quality of subjective and objective aging.

Depression can also lead to suicide, which is a significant problem in geriatric mental health. According to Hayes (1997), older adults take their lives at the highest rate of any segment of the population; greater than 50% more frequently than the nation as a whole. Hyman (2001) reported that elderly individuals who commit suicide are generally white men who have sought care from their primary health care provider instead of a mental health professional. Older white men have a suicide rate that is six times greater than the general population.

Anxiety Disorders

Anxiety disorders are significant conditions in the elderly population, but are significantly understudied. The most frequently studied indicators of the psychological status of older people are depression and life satisfaction, however anxiety disorders are twice as prevalent as depression (Wykle & Musil, 1993). The Surgeon General (1999) reported that about 11.4% of community-residing adults 55-years-old and older met the criteria for an anxiety disorder. In addition to the general anxiety disorders, the Surgeon General reported that posttraumatic stress disorder is likely to increase as the Vietnam veterans get older. The anxiety disorders most prevalent in older people include panic disorder, phobias, obsessive-compulsive disorder, generalized anxiety disorder, acute stress disorder, and posttraumatic stress disorder.

While anxiety disorders typically appear in early or middle adulthood, some appear for the first time after age 60 (Kaplan & Sadock, 1996). Kaplan and Sadock suggested that existential theories can help explain anxiety when there is no specifically identifiable stimulus for a chronically anxious feeling. The aged person may be coming to grips with death, significant interpersonal losses, and the losses associated with diminishing participation in important roles, such as that of worker. A related problem in the older population is anxiety sensitivity. Bravo and Silverman (2001) reported that individuals with high anxiety sensitivity have excessive fear of somatic feelings and a tendency to respond in an anxious way to arousal events. This high anxiety sensitivity often leads to hypochondriasis or hypochondriacal concerns, which leads to an over utilization of medical health care services. Anxiety sensitivity can also amplify anxiety disorders by enhancing the progression of anxiety to panic attacks or agoraphobic reactions. Bravo and Silverman illustrated this phenomenon, suggesting that a person may avoid an amusement park, not because amusement rides are dangerous, but because they fear a panic attack.

Depression and anxiety are frequently related in the elderly population, deBeurs et al. (2001) reported that, among older persons, about half of the individuals who are clinically depressed also are diagnosed with an anxiety disorder, and about one-quarter of persons who are anxious also have a diagnosis of major depression. They also reported that if an individual experiences a loss event, such as a death of a spouse, he or she is more likely to become depressed. On the other hand, if an individual perceives a threat, such as a spouse being diagnosed with cancer, he or she is more prone to develop an anxiety disorder.

Conclusions and Implications for Practice

It is now, and will increasingly be, vitally important that rehabilitation counselors have an accurate understanding of the effects of aging on cognitive function, and an awareness of the recognition and treatment of mental health disorders among the elderly. The preceding discussion of cognitive function, depression, and anxiety disorders among the elderly suggests several important implications for rehabilitation counselors.

A number of general conclusions can be garnered from this discussion. Early detection through counselor awareness, for example, is a key step in preventing the negative effects of mental illness. Also, the importance to mental health and functioning of maintaining physical and emotional health underscores the importance of health promotion and wellness, social engagement, and preventative health care for older consumers. Specific implications concerning cognitive function, depression, and anxiety are presented in the remainder of this section.

Cognitive Functioning

Regarding cognitive function, rehabilitation counselors should be cognizant of the following points when working with older clients. First, given the relationship between physical health and cognitive function, it is important to understand that while many of the problems faced by older workers may be the result of the natural consequences of aging, observed functional decline, either cognitive or physical, should not be assumed to be due to natural aging before first exploring alternative explanations. Older clients should be encouraged to maintain regular medical exams and preventative procedures. This relationship also highlights the importance of asking about, and providing consumers opportunities to report, functional problems in the course of counseling meetings.

Second, counselors should be aware, and make their older clients aware, of the importance of maintaining an active and engaging life and maintaining social support networks, possibly through, and certainly outside of employment. Also, given that some of the symptoms of depression, anxiety, dementia, and other mental health disorders may easily be confused for age-related cognitive impairment, counselors should be knowledgeable about these conditions, their signs and symptoms, and their treatment. Rehabilitation counselors can, through such awareness, play an important preventative role by recommending appropriate assessment and treatment at the first signs of impairment.

Depression

The discussion of depression suggests a number of important implications for rehabilitation counselors. First, given the prevalence of depression among the elderly, it is important that counselors are aware of and watchful for the risk factors. Depression should particularly be considered when comorbid medical illness, cognitive impairment, or the decrease or depletion of social supports are present. It is also important that counselors are aware that depression appears to have a reciprocal relationship with physical disability. In other words, not only is medical illness a risk factor for depression, but depression is a risk factor for physical disabilities (Kivelae & Pahkala, 2001).

Finally, counselors should guard against the misconception that symptoms of decreased activity level, increased social isolation, and problems sleeping represent normal components of the aging process. Rather, counselors should be vigilant for such symptoms of depression. Toward this end, depression and suicide assessment should,be considered standard practice when risk factors are present or symptoms of depression are observed or reported. (A comprehensive review of the diagnosis, assessment, treatment, and rehabilitation counseling issues associated with depression is presented in Bishop and Swett (2001)).

Anxiety

In addition to facing such issues as death and interpersonal loss, older rehabilitation counseling consumers will frequently be dealing with numerous stressful changes in employment and physical and mental health. As is the case with depression, the prevalence of anxiety disorders among the elderly underscores the need for a comprehensive understanding of the signs and symptoms of anxiety disorders such as panic disorder, phobias, obsessive-compulsive disorder, generalized anxiety disorder, acute stress disorder, and posttraumatic stress disorder.

Anxiety disorders can have a paralyzing effect on rehabilitation progress. It is important that counselors are able to identify anxiety and guide consumers toward effective treatment. Helping the consumer to address concerns and attain answers to their health and medical questions can help prevent or alleviate anxiety-producing concerns.

This article presents an overview of the rehabilitation counseling concerns associated with prevalent mental health problems among the elderly. In order to be maximally effective in this period of increased service to older consumers, rehabilitation counselors must commit themselves to an ongoing process of learning and awareness.

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Elizabeth A. Swett, Ph.D., CRC, Department of Rehabilitation Counseling, PO Box 100175, University of Florida, Gainesville, FL 32610-0175. Email: [e-mail]

Elizabeth A. Swett
University of Florida

Malachy Bishop
University of Kentucky