GeroCentral

GeroCentral

Serious Mental Illness

Serious Mental Illness (SMI) is a group of disorders characterized by the presence of psychosis, or a loss of contact from reality. Psychosis may present in the forms of delusions, hallucinations, distorted thinking, disorganized speech, disorganized behavior, or exaggerated moods. Illnesses that meet SMI criteria include schizophrenia, delusional disorder, bipolar disorder, and major depression with psychotic features. The various psychotic and mood disorders under the umbrella of SMI share genetic vulnerabilities and therefore should be viewed as a spectrum of conditions instead of as disorders with distinct etiologies (Craddock & Owen, 2005).

Approximately 140,000 older Americans have a diagnosis of schizophrenia with population estimates ranging from .4%-1% (inclusive of older adults in assistive or long-term care) (Cohen, 2003; Van Critters, Pratt, Bartels, & Jeste, 2005). Prevalence rates for older adults with schizophrenia in the community range from .02% to .06% (Copeland et al., 1998). In the general population, approximately 20% of major depressive cases exhibit psychotic symptoms, and it is estimated that 10% of older mental health patients (both inpatient and outpatient) have bipolar disorder (Depp, Loughren, Vahia, & Molinari, 2010). Of the documented bipolar cases among older adults, 60% reported psychotic symptoms (Depp & Jeste, 2004). The prevalence of SMI is anticipated to increase with the growth in older Americans over the next 30 years (Jeste et al., 1999).

Early estimates indicated that up to 89% of older adults with SMI in health care settings resided in nursing homes (Burns, 1991), and almost 10% of the nursing home population now carry an SMI diagnosis (Becker & Mehra, 2005). With the growth of assisted living facilities, there continue to be concerns regarding meeting the needs of the SMI population in residential living facilities (Molinari et al., 2008). Further, veterans with more severe psychiatric symptoms are more likely to become residents of nursing homes (Miller & Rosenheck, 2006), and those with SMI living in nursing homes have greater functional impairment and symptom burden compared to older adults with SMI living in the community (Bartels, Miles, Dums, & Levine, 2003).

The development of delusions or hallucinations may appear as symptoms of a psychotic disorder or a medical illness. Identifying the origin of psychosis in an older patient requires a medical evaluation to rule out infections, dehydration, and adverse medication interactions. Age of onset has been associated with differences in psychotic symptoms, treatment options and clinical outcomes. Early-onset schizophrenia is often categorized for those diagnosed before age of 40, late-onset schizophrenia after age 40, and very late-onset schizophrenia after age 60; however specific age thresholds are not universally utilized (Howard, Rabins, Seeman, & Jeste, 2000). Late-onset schizophrenia accounts for 23.5% of all cases and very-late onset schizophrenia accounts for 1.5% (Moran & Lawlor, 2005). Even though age classifications have been established, the appropriateness of a late-onset schizophrenia diagnosis remains controversial. The debate stems from noted differences in symptoms between early- and late-onset cases. Individuals with late-onset are more likely to report symptoms such as persecutory delusions, third-person auditory hallucinations, running commentary, and visual, tactical and olfactory hallucinations compared to those with early-onset. Some suggest a preclinical dementia diagnosis would be more appropriate in cases considered late-onset schizophrenia.

Over the life course, adults with late onset of schizophrenia are more likely to have held a job, been married, and had children in their lifetime compared to those with early-onset schizophrenia. However, cognitive impairment is more likely to be seen in late-onset schizophrenia in the areas of executive function, visuospatial ability, and verbal fluency (Rajji & Mulsant, 2008). Negative symptoms of schizophrenia (e.g., lack of interest, social withdrawal) are more likely to manifest in older patients (Jeste et al., 1988; Moran & Lawlor, 2005), making a SMI diagnosis challenging as high rates of medication use and sensory impairments also increase with age and mimic these symptoms. Recommended measures for assessing symptoms, cognitive impairment, and functional impairment among adults with SMI have been previously discussed in detail (Depp et al., 2010).

Treatment for SMI requires a comprehensive biopsychosocial approach due to heightened sensitivity to pharmacological treatments (e.g., atypical or conventional antipsychotic medications; (Moran & Lawlor, 2005). A lower rate of medication adherence among SMI populations requires closer clinical monitoring and greater emphasis on nonpharmacological treatment options. Behavioral interventions have been successful in improving social functioning, a key component for community-living (Patterson et al., 2006). As with younger adults, overall treatment for older adults should be conceptualized within a Recovery Movement framework (APA, 2013). The principles of shared decision-making in treatment planning (Emery, Woodhead, Molinari, & Hunt, 2012), acceptance of the illness but not allowing the illness to define the person, living in the least restrictive environment, promotion of family involvement, adherence to medication protocols as much as the individual with SMI will permit, and Assertive Community Treatment (ACT) programs with services provided by trained community care managers and low emotionally expressive caregivers are important treatment guidelines for any age group with SMI. Unfortunately, there is virtually no research on SMI treatment and residential options specifically tailored to the needs of older adults with SMI.

Written by Michelle Ellis, MA, and Victor Molinari, PhD, ABPP from the University of South Florida

 

GENERAL

Moran, M., & Lawlor, B. (2005). Late-life schizophrenia. Psychiatry, 4(11), 51-55. doi: 10.1383/psyt.2005.4.11.51

Moran, M., & Lawlor, B. (2005). Late-life schizophrenia. Psychiatry, 4(11), 51-55. doi: 10.1383/psyt.2005.4.11.51

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Miller, E. A., & Rosenheck, R. A. (2006). Risk of nursing home admission in association with mental illness nationally in the Department of Veteran Affairs. Medical Care 44, 343-351.

Miller, E. A., & Rosenheck, R. A. (2006). Risk of nursing home admission in association with mental illness nationally in the Department of Veteran Affairs. Medical Care 44, 343-351.

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Jeste, D. V., Harris, M. J., Pearlson, G. D., Rabins, P. V., Lesser, I., Miller, B., . . . Yassa, R. (1988). Late-onset schizophrenia: Studying clinical validity. Psychiatric Clinics of North America, 11, 1-13.

Jeste, D. V., Harris, M. J., Pearlson, G. D., Rabins, P. V., Lesser, I., Miller, B., . . . Yassa, R. (1988). Late-onset schizophrenia: Studying clinical validity. Psychiatric Clinics of North America, 11, 1-13.

Posted in reference | Tagged , | Comments Off on Jeste, D. V., Harris, M. J., Pearlson, G. D., Rabins, P. V., Lesser, I., Miller, B., . . . Yassa, R. (1988). Late-onset schizophrenia: Studying clinical validity. Psychiatric Clinics of North America, 11, 1-13.

Jeste, D. V., Alexopoulos, G. S., George, S., Bartels, S. J., Cummings, J. L., Gallo, J. J., . . . Lebowitz, B. D. (1999). Consensus statement on the upcoming crisis in geriatric mental health: Research agenda for the next 2 decades. Archives of General Psychiatry, 56(9), 848-853.

Jeste, D. V., Alexopoulos, G. S., George, S., Bartels, S. J., Cummings, J. L., Gallo, J. J., . . . Lebowitz, B. D. (1999). Consensus statement on the upcoming crisis in geriatric mental health: Research agenda for the next 2 decades. Archives of General Psychiatry, 56(9), 848-853.

Posted in reference | Tagged , | Comments Off on Jeste, D. V., Alexopoulos, G. S., George, S., Bartels, S. J., Cummings, J. L., Gallo, J. J., . . . Lebowitz, B. D. (1999). Consensus statement on the upcoming crisis in geriatric mental health: Research agenda for the next 2 decades. Archives of General Psychiatry, 56(9), 848-853.

Howard, R. J., Rabins, P. V., Seeman, T. E., & Jeste, D. V. (2000). Late-onset schizophrenia and very late-onset schizophrenia: An international consensus. The International Late Onset Schizophrenia Group. The American Journal of Psychiatry, 157, 172-178.

Howard, R. J., Rabins, P. V., Seeman, T. E., & Jeste, D. V. (2000). Late-onset schizophrenia and very late-onset schizophrenia: An international consensus. The International Late Onset Schizophrenia Group. The American Journal of Psychiatry, 157, 172-178.

Posted in reference | Tagged , | Comments Off on Howard, R. J., Rabins, P. V., Seeman, T. E., & Jeste, D. V. (2000). Late-onset schizophrenia and very late-onset schizophrenia: An international consensus. The International Late Onset Schizophrenia Group. The American Journal of Psychiatry, 157, 172-178.

Emery, E., Woodhead, E., Molinari, V., & Hunt, M. G. (2012). Treatment adherence in late life (2nd ed.). New York: John Wiley & Sons.

Emery, E., Woodhead, E., Molinari, V., & Hunt, M. G. (2012). Treatment adherence in late life (2nd ed.). New York: John Wiley & Sons.

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Craddock, N., & Owen, M. J. (2005). The beginning of the end for the Kraepelinian dichotomy. British Journal of Psychiatry, 186, 364-366.

Craddock, N., & Owen, M. J. (2005). The beginning of the end for the Kraepelinian dichotomy. British Journal of Psychiatry, 186, 364-366.

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Copeland, J. R. M., Dewey, M. E., Scott, A., Gilmore, C., Larkin, B. A., Cleave, N., . . . McKibbin, P. (1998). Schizophrenia and delusional disorder in older age: Community prevalence, incidence, comorbidity, and outcome. Schizophrenia Bulletin, 24, 153-161.

Copeland, J. R. M., Dewey, M. E., Scott, A., Gilmore, C., Larkin, B. A., Cleave, N., . . . McKibbin, P. (1998). Schizophrenia and delusional disorder in older age: Community prevalence, incidence, comorbidity, and outcome. Schizophrenia Bulletin, 24, 153-161.

Posted in reference | Tagged , | Comments Off on Copeland, J. R. M., Dewey, M. E., Scott, A., Gilmore, C., Larkin, B. A., Cleave, N., . . . McKibbin, P. (1998). Schizophrenia and delusional disorder in older age: Community prevalence, incidence, comorbidity, and outcome. Schizophrenia Bulletin, 24, 153-161.

Cohen, C. I. (2003). Schizophrenia into later life: Treatment, research, and policy. Washington, D.C.: American Psychiatric Publishing.

Cohen, C. I. (2003). Schizophrenia into later life: Treatment, research, and policy. Washington, D.C.: American Psychiatric Publishing.

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Burns, B. J. (1991). The elderly with chronic mental illness. New York: Springer.

Burns, B. J. (1991). The elderly with chronic mental illness. New York: Springer.

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Gilmer, T., Ojeda, V.D., Folson, D., Fuentes, D., Criado, V., Garcia, P., & Jeste, D. (2006). Costs of community-based public mental health services for older adults: variations related to age and diagnosis. International Journal of Geriatric Psychiatry, 21, 1121-1126.

Gilmer, T., Ojeda, V.D., Folson, D., Fuentes, D., Criado, V., Garcia, P., & Jeste, D. (2006).  Costs of community-based public mental health services for older adults: variations related to age and diagnosis.  International Journal of Geriatric Psychiatry, 21, 1121-1126.

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Lin, W.C., Zhang, J., Leung, G.Y., & Clark, R.E. (2011). Chronic physical conditions in older adults with mental illness and/ or substance use disorders. Journal of the American Geriatric Society, 59(10), 1913-21. doi: 10.1111/j.1532-5415.2011.03588.x

Lin, W.C., Zhang, J., Leung, G.Y., & Clark, R.E. (2011). Chronic physical conditions in older adults with mental illness and/ or substance use disorders. Journal of the American Geriatric Society, 59(10), 1913-21. doi: 10.1111/j.1532-5415.2011.03588.x

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Rajji, T.K., & Mulsant, B.H. (2008). Nature and course of cognitive function in late-life schizophrenia: a systematic review. Schizophrenia Research, 102 (1-3), 122-140.

Rajji, T.K., & Mulsant, B.H. (2008). Nature and course of cognitive function in late-life schizophrenia: a systematic review.  Schizophrenia Research, 102 (1-3), 122-140.

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Molinari, V., Merritt, S., Mills, W., Chiriboga, D., Conboy, A., Hyer, K., & Becker, M. (2008). Serious mental illness in Florida nursing homes: Need for training. Gerontology and Geriatrics Education, 29 (1), 66-83.

Molinari, V., Merritt, S., Mills, W., Chiriboga, D., Conboy, A., Hyer, K., & Becker, M. (2008). Serious mental illness in Florida nursing homes: Need for training. Gerontology and Geriatrics Education, 29 (1), 66-83.

Posted in reference | Tagged , , , , | Comments Off on Molinari, V., Merritt, S., Mills, W., Chiriboga, D., Conboy, A., Hyer, K., & Becker, M. (2008). Serious mental illness in Florida nursing homes: Need for training. Gerontology and Geriatrics Education, 29 (1), 66-83.

Depp, C. A. & Jeste, D. V. (2004). Bipolar disorder in older adults: a critical review. Bipolar Disorder, 6(5), 343-367.

Depp, C. A. & Jeste, D. V. (2004). Bipolar disorder in older adults: a critical review. Bipolar Disorder, 6(5), 343-367.

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Bartels, S. J., Miles, K. M., Dums, A. R., & Levine, K. J. (2003). Are nursing homes appropriate for older adults with severe mental illness? Conflicting consumer and clinician views and implications for the Olmstead decision. Journal of the American Geriatrics Society, 51(11), 1571.

Bartels, S. J., Miles, K. M., Dums, A. R., & Levine, K. J. (2003). Are nursing homes appropriate for older adults with severe mental illness? Conflicting consumer and clinician views and implications for the Olmstead decision. Journal of the American Geriatrics Society, 51(11), 1571.

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ASSESSMENT OF SERIOUS MENTAL ILLNESS IN LATER LIFE

Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.

Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

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Granholm, E., McQuaid, J. R., Link, P. C., Fish, S., Patterson, T., & Jeste, D. V. (2008). Neuropsychological predictors of functional outcome in Cognitive Behavioral Social Skills Training for older people with schizophrenia. Schizophrenia Research, 100(1-3), 133-143. doi:10.1016/j.schres.2007.11.032

Granholm, E., McQuaid, J. R., Link, P. C., Fish, S., Patterson, T., & Jeste, D. V. (2008). Neuropsychological predictors of functional outcome in Cognitive Behavioral Social Skills Training for older people with schizophrenia. Schizophrenia Research, 100(1-3), 133-143. doi:10.1016/j.schres.2007.11.032

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Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Posted in reference | Tagged , , , , , | Comments Off on Edelstein, B., Woodhead, E., Segal, D., Heisel, M., Bower, E., Lowery, A., & Stoner, S. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist, 31 , 1-35.

Depp, C., Loughran, C., Vahia, I., & Molinari, V. (2010). Assessing psychosis in acute and chronically mentally ill older adults. In P. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed.) (pp.123-154). New York: John Wiley & Sons.

Depp, C., Loughran, C., Vahia, I., & Molinari, V. (2010). Assessing psychosis in acute and chronically mentally ill older adults. In P. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed.) (pp.123-154). New York: John Wiley & Sons.

Posted in reference | Tagged , , , , | Comments Off on Depp, C., Loughran, C., Vahia, I., & Molinari, V. (2010). Assessing psychosis in acute and chronically mentally ill older adults. In P. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed.) (pp.123-154). New York: John Wiley & Sons.

TREATMENT FOR SERIOUS MENTAL ILLNESS IN LATER LIFE

Van Citters, A. D., Pratt, S. I., Bartels, S. J., & Jeste, D. V. (2005). Evidence-based review of pharmacological and nonpharmacological treatments for older adults with schizophrenia. Psychiatric Clinics of North America, 28, 913-939. doi: 10.1016/j.psc.2005.08.001

Van Citters, A. D., Pratt, S. I., Bartels, S. J., & Jeste, D. V. (2005). Evidence-based review of pharmacological and nonpharmacological treatments for older adults with schizophrenia. Psychiatric Clinics of North America, 28, 913-939. doi: 10.1016/j.psc.2005.08.001

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American Psychological Association. (2013). Recovery to practice training models. Retrieved 12/1/13, from http://www.apa.org/pi/mfp/psychology/recovery-to-practice/training.aspx

American Psychological Association. (2013). Recovery to practice training models. Retrieved 12/1/13, from http://www.apa.org/pi/mfp/psychology/recovery-to-practice/training.aspx

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Berry, K., & Barrowclough, C. (2009). The needs of older adults with schizophrenia: implications for psychological interventions. Clinical Psychology Review, 29, 68-76. : 10.1016/j.cpr.2008.09.010.

Berry, K., & Barrowclough, C. (2009). The needs of older adults with schizophrenia: implications for psychological interventions.  Clinical Psychology Review, 29, 68-76. : 10.1016/j.cpr.2008.09.010.

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Street, D., Molinari V., & Cohen, D. (in press). State policies for nursing home residents with Serious Mental Illness. Community Mental Health Journal. doi: 10.1007/s10597-012-9527-9

Street, D., Molinari V., & Cohen, D. (in press). State policies for nursing home residents with Serious Mental Illness. Community Mental Health Journal. doi: 10.1007/s10597-012-9527-9

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Patterson, T. L., Mausbach, B. T., McKibbin, C., Goldman, S., Bucardo, J., & Jeste, D. V. (2006). Functional Adaptation Skills Training (FAST): A randomized trial of a psychosocial intervention for middle-aged and older patients with chronic psychotic disorders. Schizophrenia Research, 86, 291-299.

Patterson, T. L., Mausbach, B. T., McKibbin, C., Goldman, S., Bucardo, J., & Jeste, D. V. (2006). Functional Adaptation Skills Training (FAST): A randomized trial of a psychosocial intervention for middle-aged and older patients with chronic psychotic disorders. Schizophrenia Research, 86, 291-299.

Posted in reference | Tagged , , , | Comments Off on Patterson, T. L., Mausbach, B. T., McKibbin, C., Goldman, S., Bucardo, J., & Jeste, D. V. (2006). Functional Adaptation Skills Training (FAST): A randomized trial of a psychosocial intervention for middle-aged and older patients with chronic psychotic disorders. Schizophrenia Research, 86, 291-299.

Kim, K.Y. & Goldstein, M. Z. (1997). Treating older adults with psychotic symptoms. Psychiatric Services, 48 (9), 1123-1126.

Kim, K.Y. & Goldstein, M. Z. (1997). Treating older adults with psychotic symptoms. Psychiatric Services, 48 (9), 1123-1126.

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Granholm, E., McQuaid, J. R., McClure, F., Auslander, L. A., Perivoliotis, D., Pedrelli, P., & … Jeste, D. V. (2005). A Randomized, Controlled Trial of Cognitive Behavioral Social Skills Training for Middle-Aged and Older Outpatients With Chronic Schizophrenia. The American Journal Of Psychiatry, 162(3), 520-529. doi:10.1176/appi.ajp.162.3.520

Granholm, E., McQuaid, J. R., McClure, F., Auslander, L. A., Perivoliotis, D., Pedrelli, P., & … Jeste, D. V. (2005). A Randomized, Controlled Trial of Cognitive Behavioral Social Skills Training for Middle-Aged and Older Outpatients With Chronic Schizophrenia. The American Journal Of Psychiatry, 162(3), 520-529. doi:10.1176/appi.ajp.162.3.520

Posted in reference | Tagged , , | Comments Off on Granholm, E., McQuaid, J. R., McClure, F., Auslander, L. A., Perivoliotis, D., Pedrelli, P., & … Jeste, D. V. (2005). A Randomized, Controlled Trial of Cognitive Behavioral Social Skills Training for Middle-Aged and Older Outpatients With Chronic Schizophrenia. The American Journal Of Psychiatry, 162(3), 520-529. doi:10.1176/appi.ajp.162.3.520

Granholm, E., McQuaid, J. R., Link, P. C., Fish, S., Patterson, T., & Jeste, D. V. (2008). Neuropsychological predictors of functional outcome in Cognitive Behavioral Social Skills Training for older people with schizophrenia. Schizophrenia Research, 100(1-3), 133-143. doi:10.1016/j.schres.2007.11.032

Granholm, E., McQuaid, J. R., Link, P. C., Fish, S., Patterson, T., & Jeste, D. V. (2008). Neuropsychological predictors of functional outcome in Cognitive Behavioral Social Skills Training for older people with schizophrenia. Schizophrenia Research, 100(1-3), 133-143. doi:10.1016/j.schres.2007.11.032

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MEASURES OF SERIOUS MENTAL ILLNESS IN LATER LIFE

Coming soon from the University of Alabama!