2

Assessing the Service Needs of
Older Adults with Mental Health
and Substance Use Conditions

Abstract: This chapter analyzes the available information about the prevalence of mental health and substance use (MH/SU) conditions in older adults and identifies the additional information required to plan for a workforce capable of meeting their current and future service needs. The committee estimates that in 2010, at least 5.6 to 8 million older adults had one or more MH/SU conditions. Several million more older adults were probably also affected, but the available data are not adequate to estimate the number. By 2030, expected growth in the older population will increase the number of older people with MH/SU conditions by 80 percent. Many older adults with MH/SU conditions also have physical health conditions and cognitive, functional, and sensory impairments that can complicate the detection, diagnosis, and treatment of their MH/SU conditions and create difficult caregiving situations for their families and professional and other service providers. In 2010, MH/SU conditions were the eighth most costly type of health care conditions for older adults in the United States, but most older adults with these conditions still do not receive the MH/SU services they need.

An in-depth understanding of the service needs of a target population is integral to analyzing the requirements for a workforce capable of meeting those needs. Thus, the objectives of this chapter are twofold:



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2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions Abstract: This chapter analyzes the available information about the prevalence of mental health and substance use (MH/SU) conditions in older adults and identifies the additional information required to plan for a workforce capable of meeting their current and future service needs. The committee estimates that in 2010, at least 5.6 to 8 million older adults had one or more MH/SU conditions. Several million more older adults were probably also affected, but the available data are not adequate to estimate the number. By 2030, expected growth in the older population will increase the number of older people with MH/SU con- ditions by 80 percent. Many older adults with MH/SU conditions also have physical health conditions and cognitive, functional, and sensory impairments that can complicate the detection, diagnosis, and treatment of their MH/SU conditions and create difficult caregiving situations for their families and professional and other service providers. In 2010, MH/SU conditions were the eighth most costly type of health care conditions for older adults in the United States, but most older adults with these conditions still do not receive the MH/SU services they need. An in-depth understanding of the service needs of a target popula- tion is integral to analyzing the requirements for a workforce capable of meeting those needs. Thus, the objectives of this chapter are twofold: 39

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40 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS first, to describe what is known about the prevalence of mental health and substance use (MH/SU) conditions in older adults and their related service needs, and second, to consider the impact of population trends, particularly the aging of the baby boomer cohort and growing popula - tion diversity, on the makeup of the older population and future needs for MH/SU services. The first two sections of the chapter describe the MH/SU conditions that occur in older adults and present the best available information about the proportion and number of older adults that have one or more of the conditions. The third section provides information about prevalence rates for important subgroups of the older population, including racial and ethnic groups and veterans. Later sections describe the coexisting physical health conditions and cognitive and functional impairments that shape the MH/SU service needs of older adults; review the impact of MH/SU conditions; and discuss the available data on use of MH/SU services by older adults and factors that could affect their future MH/SU service needs. The last section summarizes the chapter findings about the current and future MH/SU service needs of the older population. Unfortunately, much of the information required to analyze their MH/SU service needs and plan for a workforce capable of meeting those needs is not available. Additional information needed for these purposes is discussed. MH/SU CONDITIONS IN OLDER ADULTS The Institute of Medicine committee identified 27 MH/SU conditions for attention in this report because of their importance in older adults and their implications for service needs and workforce requirements. Fifteen of the conditions, including two substance use conditions, are defined by explicit criteria in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) (APA, 2000), the accepted source for diagnostic classification of MH/SU conditions in the United States. These conditions are referred to as mental disorders in this report. The other 12 conditions are symptoms or clusters of symptoms not classified as mental disorders in DSM-IV-TR. These con - ditions are referred to as other MH/SU conditions in the report. Two of the 15 DSM-IV-TR mental disorders, bipolar disorder and schizophrenia, constitute the core of a category of mental health condi - tions usually referred to as serious mental illness (SMI). SMI is often defined to include severe forms of other DSM-IV-TR mental disorders, such as major depression, but it does not include substance use conditions. Box 2-1 describes each of the 27 MH/SU conditions identified by the committee, focusing primarily on symptoms. Descriptions of the 15 DSM- IV-TR mental disorders are taken from the DSM-IV-TR manual. Descrip-

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41 ASSESSING THE SERVICE NEEDS tions of the 12 other MH/SU conditions are compiled from published reports. As discussed later in the chapter, substantial numbers of older adults have more than one of the 27 conditions. The DSM-IV-TR does not provide diagnostic criteria specifically for older adults, and clinicians and researchers have noted that some of the criteria for DSM-IV-TR mental disorders include symptoms that are expressed less often in older adults than younger people with the condi - tions. Several studies have shown, for example, that older adults with DSM-IV-TR depressive disorders are significantly less likely than younger people with these disorders to exhibit the depressed mood and sadness that are the first listed criteria for the disorders (Gallo et al., 1994, 1999). Likewise, older adults with bipolar disorder are somewhat less likely to exhibit the manic symptoms that are required criteria for the disorder (Coryell et al., 2009; Depp and Jeste, 2004; Hirschfeld and Vornik, 2004). Diagnostic criteria for DSM mental disorders are established with the publication of the most recent version of the manual, but clinicians, researchers, and others continue to debate the criteria for existing dis - orders and whether additional MH/SU conditions should be included as disorders in the next version of the manual. The forthcoming DSM-5, scheduled for publication in 2013, will include criteria for diagnosing some new mental disorders, eliminate some disorders, and revise the criteria for many other disorders. It is likely, for example, that hoarding, one of the other MH/SU conditions identified by the IOM committee as important for older adults, will be included as a mental disorder in the DSM-5 (APA, 2010). Thus, the designation of which MH/SU conditions are defined as DSM mental disorders, although set for years at a time, is also changeable. The committee’s decision to identify both DSM-IV-TR mental dis- orders and other MH/SU conditions for special attention in this report reflects the report’s focus on the service needs of older adults and work - force requirements and competencies to meet those needs. As described in Box 2-1, both DSM-IV-TR mental disorders and other MH/SU conditions result in significant emotional distress, functional disability, and reduced quality of life for the person. In addition, at least four types of age-related factors can cause, complicate, and exacerbate MH/SU conditions. The four factors are physiological effects of normal aging; changes in life circumstances that frequently occur in old age; coexisting physical health conditions that are common in older adults; and cognitive, functional, and sensory impairments that affect substantial numbers of older adults, espe- cially those age 75 and older. In the presence of these age-related factors, MH/SU conditions that do not meet the criteria for a DSM-IV-TR mental disorder can result in pressing and sustained needs for MH/SU services.

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42 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS BOX 2-1 Symptoms of MH/SU Conditions Identified as Important for Older Adults DSM-IV-TR Category Depressive Disorders 1. Major Depressive Disorder is a DSM-IV-TR mental disorder char- acterized by one or more Major Depressive Episodes. Major Depressive Disorder and Major Depressive Episode (described below) are often referred to as major depression. 2. Major Depressive Episode is a period of at least 2 weeks in which the person has five or more of nine symptoms nearly every day, including at least one of the first two: (1) depressed mood that lasts most of the day, as indicated by either subjective report (e.g., the person feels sad or empty) or observations of others (e.g., the person appears tearful); or (2) markedly diminished in- terest or pleasure in all or nearly all activities that lasts most of the day. The seven additional symptoms are (3) significant weight loss when not dieting, weight gain, or decrease or increase in appetite; (4) insomnia or hypersomnia; (5) psychomotor agita- tion or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt; (8) diminished ability to think or concentrate, or indecisiveness; and (9) recur- rent thoughts of death (not just fear of dying), recurrent suicidal ideation, a suicide plan, or a suicide attempt (APA, 2000). 3. Dysthymic Disorder is a DSM-IV-TR mental disorder character- ized by at least 2 years of depressed mood that lasts most of the day for more days than not, accompanied by at least two of the following additional symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. In the 2-year period, any symptom-free intervals must last no longer than 2 months (APA, 2000). DSM-IV-TR Bipolar Disorders 4. DSM-IV-TR Bipolar Disorders I and II. Bipolar I Disorder is a mental disorder characterized by one or more Manic Episodes or Mixed Episodes (described below), often accompanied by a history of major depressive episodes (APA, 2000). Bipolar II Dis- order is a mental disorder characterized by one or more major depressive episodes accompanied by at least one Hypomanic

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43 ASSESSING THE SERVICE NEEDS Episode (APA, 2000). Bipolar I and II disorders are usually re- ferred to as bipolar disorder. A Manic Episode is a period of at least 1 week in which the person has an abnormally and persistently elevated, expansive, or irritable mood. The mood disturbance must be accompanied by at least three of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usu- al or pressured speech, flight of ideas, distractibility, increased goal-directed activities or psychomotor agitation, and exces- sive involvement in pleasurable activities with a high potential for painful outcomes (e.g., buying sprees, sexual indiscretions, or foolish business investments) (APA, 2000). A Mixed Episode is a period of at least 1 week in which the criteria for both a manic episode and a major depressive epi- sode are met nearly every day. The person has rapidly alternating moods (sadness, irritability, euphoria) often accompanied by agi- tation, insomnia, appetite dysregulation, psychosis, and suicidal thinking (APA, 2000). DSM-IV-TR Anxiety Disorders 5. Panic Disorder is a DSM-IV-TR mental disorder characterized by recurrent unexpected panic attacks followed by at least 1 month of persistent concern about having another panic attack, worry about the consequences of an attack, or a significant change in behavior to avoid panic attacks. A panic attack is a discrete pe- riod in which the person experiences sudden intense apprehen- sion, fear, or terror in the absence of real danger. It must be ac- companied by at least 4 of 13 additional symptoms: palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; feel- ings of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded or faint; feelings of unreality or being detached from oneself; fear of losing control or going crazy; fear of dying; numbness or tingling sensations; and chills or hot flashes. Panic disorder can occur with or without agoraphobia (APA, 2000). 6. Agoraphobia Without Panic is a DSM-IV-TR mental disorder characterized by anxiety about, or avoidance of, places or situa- tions in which escape might be difficult or embarrassing or help might not be available in the event of a panic attack or panic-like symptoms. The person must not have a history of panic attacks. continued

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44 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS BOX 2-1 Continued Agoraphobic fears typically involve specific situations, such as being outside the home alone; being in a crowd; standing in a line; being on a bridge; or traveling in a bus, train, or car (APA, 2000). 7. Social Phobia is a DSM-IV-TR mental disorder characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations in which embarrass- ment may occur. The person usually tries to avoid the feared situ- ation. The fear and/or avoidance must interfere significantly with the person’s normal routine, occupational functioning, or social activities or relationships (APA, 2000). 8. Obsessive-Compulsive Disorder is a DSM-IV-TR mental disorder characterized by recurrent obsessions and/or compulsions. Ob- sessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause anxiety or distress. Examples are repeated thoughts about contamina- tion, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses, and sexual imagery. Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., counting and repeating words silently), the goal of which is to prevent or reduce anxiety or distress. The com- pulsion is usually intended to reduce distress related to the ob- session or to prevent a dreaded event or situation (APA, 2000). 9. Generalized Anxiety Disorder is a DSM-IV-TR mental disorder characterized by persistent, excessive anxiety and worry that oc- curs most days for at least 6 months. The intensity, duration, or frequency of these symptoms is far out of proportion to the likeli- hood or impact of the feared event. The symptoms are accompa- nied by at least three of six additional symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty con- centrating, irritability, muscle tension, and disturbed sleep. The person may not realize the anxiety and worry are excessive but is distressed by constant worry, difficulty controlling the worry, and related impairments in important areas of functioning (APA, 2000). 10. Posttraumatic Stress Disorder (PTSD) is a DSM-IV-TR mental dis- order characterized by symptoms that develop after exposure to an extremely traumatic event involving either (1) direct personal experience of threatened death, serious injury, or other threat

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45 ASSESSING THE SERVICE NEEDS to one’s physical integrity; or (2) witnessing an event involving death, injury, or a threat to the physical integrity of another per- son, or learning about unexpected or violent death, serious harm, or threat of death or injury to a family member or other close associate. The person’s response to the event must involve in- tense fear, helplessness, or horror, and the symptoms must last more than 1 month and include persistent reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent arousal (e.g., rapid heart rate). Traumatic events experienced directly include military combat, violent personal assault, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or diagnosis of a life-threatening illness. The disorder may be especially severe or long-lasting when the stressor is of human design (e.g., torture or rape) (APA, 2000). DSM-IV-TR Schizophrenia and Other Psychotic Disorders 11. Schizophrenia is a DSM-IV-TR mental disorder that lasts for at least 6 months, including at least 1 month during which the person has two or more of the following: positive symptoms (delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior), and/or negative symptoms (restrictions in the range and intensity of emotional expression, the fluency and productivity of thought and speech, and the initiation of goal- directed behavior). For a significant portion of the time after on- set of the disorder, the person’s functioning in one or more major areas, such as work, interpersonal relations, and self-care, must be markedly below his or her prior functioning (APA, 2000). In 2000, an international panel recommended two new clas- sifications: late-onset schizophrenia, with onset after age 45, and very-late-onset schizophrenia, with onset after age 60 (Howard et al., 2000). DSM-IV-TR criteria do not list these classifications, but the DSM-IV-TR manual discusses late-onset schizophrenia (APA, 2000), and a late-onset specification code can be added to identify the conditions. DSM-IV-TR Substance-Related Disorders Substance Dependence and Substance Abuse are defined similarly for alcohol and other sub- stances (described below). A person with a DSM-IV-TR diagnosis of continued

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46 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS BOX 2-1 Continued Substance Dependence cannot also have a DSM-IV-TR diagnosis of Substance Abuse. 12. Alcohol Dependence and Alcohol Abuse are DSM-IV-TR mental disorders that meet the requirements for substance dependence and abuse defined with respect to alcohol. 13. Drug Dependence and Drug Abuse are DSM-IV-TR mental disor- ders that meet the requirements for substance dependence and abuse defined with respect to illicit drugs and prescribed or over- the-counter drugs used for nonmedical purposes, including am- phetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, sedatives, hypnotics, and antianxiety drugs (APA, 2000). Substance Dependence is a cluster of symptoms indicating the person continues to use the substance despite significant substance-related impairment or distress. The pattern of re- peated self-administration must result in three or more of seven symptoms in three categories: tolerance, withdrawal, and com- pulsive drug-taking behavior (APA, 2000). Substance Abuse is a maladaptive pattern of substance use leading to clinically significant impairment or distress as mani- fested by one (or more) of the following, occurring within a 12-month period: (1) failure to fulfill major role obligations; (2) recurrent substance use in situations in which it is physically haz- ardous; (3) recurrent substance-related legal problems; and (4) continued use despite recurrent social or interpersonal problems caused or exacerbated by the substance use (APA, 2000). DSM-IV-TR Adjustment Disorders 14. Adjustment Disorder is a DSM-IV-TR mental disorder character- ized by a psychological or behavioral response to an identifiable stressor that results in clinically significant emotional or behav- ioral symptoms. The symptoms must occur within 3 months of the onset of the stressor and resolve within 6 months after the stressor is resolved. The person must have marked distress that is in excess of what would be expected given the nature of the stressor or significant impairment in social or occupational func- tioning (APA, 2000).

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47 ASSESSING THE SERVICE NEEDS DSM-IV-TR Personality Disorders 15. Personality Disorders are DSM-IV-TR mental disorders charac- terized by an enduring pattern of inner experience and behav- ior that deviates markedly from the expectations of the person’s culture, is pervasive and inflexible, and leads to distress or im- pairment. The onset of the disorder can be traced back to ad- olescence or early adulthood. The 10 personality disorders are paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive per- sonality disorder (APA, 2000). MH/SU Conditions That Are Not DSM-IV-TR Disorders 16. Depressive Symptoms is a term to describe symptoms, such as depressed mood and feelings of worthlessness and guilt, that do not meet the criteria for a diagnosis of a DSM-IV-TR depressive disorder, usually because of insufficient duration, number, or se- verity. Other terms for such symptoms are subsyndromal depres- sion, subthreshold depression, subclinical depression, and minor depression (Blazer, 2003; Lavretsky and Kumar, 2002; Lyness et al., 2009). 17. Anxiety Symptoms is a term to describe symptoms, such as ex- cessive nervousness, worry, and fear or avoidance of anxiety- causing situations that do not meet the criteria for a DSM-IV-TR diagnosis of an anxiety disorder, usually because of insufficient number or severity. Other terms for such symptoms are subsyn- dromal anxiety and subthreshold anxiety (Grenier et al., 2011; Lenze and Wetherell, 2011). 18. At-Risk Drinking is a term to describe alcohol-related symptoms that do not meet the criteria for a DSM-IV-TR diagnosis of alcohol dependence or abuse, usually because of insufficient number or severity. Symptoms of at-risk drinking include having more than a specified number of drinks (usually 2 per day); binge drink- ing, and exhibiting any of the symptoms of alcohol dependence or abuse (e.g., tolerance, withdrawal, compulsive alcohol use behaviors, failure to fulfill major role obligations, and recurrent alcohol-related legal, social, or interpersonal problems). Other terms for such symptoms are subsyndromal alcohol dependence, subthreshold alcohol dependence, alcohol misuse, and problem continued

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48 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS BOX 2-1 Continued drinking (APA, 2000; Berks and McCormick, 2008; Blazer and Wu, 2009a, 2011; Blow and Barry, 2002; Merrick et al., 2008). 19. At-Risk Drug Use is a term to describe drug-related symptoms that do not meet the criteria for a DSM-IV-TR diagnosis of drug dependence or abuse, usually because of insufficient number or severity. Symptoms of at-risk drug use include drug overdoses and any of the symptoms of drug dependence and abuse (e.g., tolerance, withdrawal, compulsive drug use behaviors, failure to fulfill major role obligations, and recurrent drug-related legal, so- cial, or interpersonal problems). Other terms for such symptoms are subthreshold drug dependence, at-risk use of psychoactive drugs, and extra-medical drug use (Blazer and Wu, 2009b,c; Degenhardt et al., 2007; Wu and Blazer, 2011). 20. Suicidal Ideation is a term to describe serious thoughts about suicide and death. It is sometimes subdivided into active suicidal ideation (e.g., thinking about taking one’s own life) and passive suicidal ideation or passive death ideation (e.g., feeling that life is not worth living and wishing one were dead) (Bartels et al., 2002; Beck et al., 1979; Paykel et al., 1974; Raue et al., 2007). 21. Suicide Plans and Attempts are terms to describe plans and be- haviors to kill oneself. Suicide plans can include selecting a time when one will be alone and therefore able to kill oneself, selecting a means for killing oneself, and obtaining the means for killing oneself. Suicide attempts are active behaviors to end one’s life. Suicidal ideation, suicide plans, and suicide attempts are in- cluded as one of the nine symptoms of a DSM-IV-TR major de- pressive episode (APA, 2000). 22. Behavioral and Psychiatric Symptoms Associated with Dementia is a term to describe noncognitive symptoms of diseases and conditions that cause dementia. Such symptoms include de- lusions, hallucinations, agitation, verbal aggression; physical aggression, anxiety, apathy, depression, dysphoria, irritability, elation, euphoria, aberrant motor behavior, appetite and eating disorders, sleep disorders; inappropriate sexual behavior; and unsafe wandering. Other terms for such symptoms are neuropsy- chiatric symptoms of dementia and behavioral and psychological symptoms of dementia (Chan et al., 2003; Cohen-Mansfield et al., 1989; Cummings et al., 1994; Jeste and Finkel, 2000; Lyketsos

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49 ASSESSING THE SERVICE NEEDS et al., 2000; McNeese et al., 2009; Smith and Buckwalter, 2005; Teri et al., 1992). DSM-IV-TR defines diagnostic criteria for several dementia- related mental disorders, and coding specifications for behavioral and psychiatric symptoms can be added to these disorders, but behavioral and psychiatric symptoms associated with dementia are not classified as DSM-IV-TR mental disorders. 23. Hoarding is a term to describe symptoms, such as the accumu- lation of a large volume of paper, newspapers, containers, food, books, trash, and other materials that clutter living areas to the extent that they cannot be used for their intended purposes. Se- vere hoarding can create health and safety hazards for the per- son and others living in the same home, building, or community. The person is often unaware of the problem, but it may result in a referral or complaint to a public health, adult protective services, or case management agency. Another term for these symptoms is compulsive hoarding (Ayers et al., 2010; Frost et al., 2000; Kim et al., 2001; Pertusa et al., 2008). 24. Severe Domestic Squalor is a term to describe a living situation, often from the perspective of a public health or adult protec- tive services worker who is responding to a referral or complaint. The living situation is said to be filthy; cluttered with dirt, gar- bage, and rubbish; and infested with vermin, excrement, and de- composing food. Visitors experience disgust and revulsion, and the smell is sometimes said to be unbearable to all except the occupant, who often refuses help to clean the living situation (Snowdon and Halliday, 2011; Snowdon et al., 2007). 25. Severe Self-Neglect is a term used to describe health-related symptoms, such as malnutrition, dehydration, untreated medical conditions, and hazardous living conditions, that result from a person’s failure to provide for his or her own needs. The National Center on Elder Abuse says that self-neglect “generally manifests itself in an older person as a refusal or failure to provide him- self/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions” (NCEA, 2011). Severity of self-neglect is usually defined in the do- mains of personal hygiene, cleanliness, health needs, household and environmental hazards, and home safety (Dong et al., 2010; Kelly et al., 2008). continued

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