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. Over the years, evidence-based programs have been developed that have implemented social skills training (Granholm et al., 2007; Mueser et al., 2010), and illness management protocols in improving the physical and psychiatric self-management skills for older adults with SMI (Bartels et al., 2014). More innovate treatments for the older adult population with SMI in community, hospital, and long term care settings are needed, especially those that train staff to address the unique needs of older adults with SMI (Molinari et al., 2017; Muralidharan, Mills, Evans, Fujii, & Molinari, 2019), and that determine how to encourage those with SMI to be more active in taking care of their health (Muralidharan, Klingaman, Molinari, & Goldstein, 2018).
Written by Michelle Ellis, MA, and Victor Molinari, PhD, ABPP from the University of South Florida
GENERAL
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.
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.
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.
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.
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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.
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.
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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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
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.
Molinari, V., Hobday, J., Roker, R., Kunik, M. Kane, R.A., Kaas, M., Mehrotra, C., Williams, C, Robbins, J.C., & Dobbs, D. (2017). Impact of Serious Mental Illness online training for certified nursing assistants in long term care. Gerontology & Geriatrics Education, 38(4), 359-374. http://dx.doi.org/10.1080/02701960.2016.1188811
Molinari, V., Hobday, J., Roker, R., Kunik, M. Kane, R.A., Kaas, M., Mehrotra, C., Williams, C, Robbins, J.C., & Dobbs, D. (2017). Impact of Serious Mental Illness online training for certified nursing assistants in long term care. Gerontology & Geriatrics Education, 38(4), 359-374. http://dx.doi.org/10.1080/02701960.2016.1188811
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.
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
Muralidharan, A., Klingaman, E., Molinari, V., Goldberg, R. (2018). Perceived barriers to physical activity older and younger veterans with Serious Mental Illness. Psychiatric Rehabilitation Journal, 41(1), 67-71. http://dx.doi.org/10.1037/prj0000245
Muralidharan, A., Klingaman, E., Molinari, V., Goldberg, R. (2018). Perceived barriers to physical activity older and younger veterans with Serious Mental Illness. Psychiatric Rehabilitation Journal, 41(1), 67-71. http://dx.doi.org/10.1037/prj0000245
Muralidharan, A., Mills, W., Evans, D., Fujii, D., & Molinari, V. (2019). Preparing long-term care staff to meet the needs of aging persons with Serious Mental Illness. Journal of the American Medical Directors Association, 20, 683-688. https://www.jamda.com/article/S1525-8610(19)30305-6/pdf
Muralidharan, A., Mills, W., Evans, D., Fujii, D., & Molinari, V. (2019). Preparing long-term care staff to meet the needs of aging persons with Serious Mental Illness. Journal of the American Medical Directors Association, 20, 683-688. https://www.jamda.com/article/S1525-8610(19)30305-6/pdf
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.
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.
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.
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.
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
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.
Molinari, V., Hobday, J., Roker, R., Kunik, M. Kane, R.A., Kaas, M., Mehrotra, C., Williams, C, Robbins, J.C., & Dobbs, D. (2017). Impact of Serious Mental Illness online training for certified nursing assistants in long term care. Gerontology & Geriatrics Education, 38(4), 359-374. http://dx.doi.org/10.1080/02701960.2016.1188811
Molinari, V., Hobday, J., Roker, R., Kunik, M. Kane, R.A., Kaas, M., Mehrotra, C., Williams, C, Robbins, J.C., & Dobbs, D. (2017). Impact of Serious Mental Illness online training for certified nursing assistants in long term care. Gerontology & Geriatrics Education, 38(4), 359-374. http://dx.doi.org/10.1080/02701960.2016.1188811
TREATMENT FOR SERIOUS MENTAL ILLNESS IN LATER LIFE
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
Bartels, S. J., Pratt, S. I., Mueser, K. T., Naslund, J. A., Wolfe, R. S., Santos, M., Xie, H., & Riera, E. G. (2014). Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with Serious Mental Illness Psychiatr Services, 65(3): 330–337.
Bartels, S. J., Pratt, S. I., Mueser, K. T., Naslund, J. A., Wolfe, R. S., Santos, M., Xie, H., & Riera, E. G. (2014). Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with Serious Mental Illness Psychiatr Services, 65(3): 330–337.
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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.
Granholm E., McQuaid J.R., McClure, F.S., Link, P.C., Perivoliotis, D., Gottlieb, J.D., Jeste, D.V. (2007). Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up. Journal of Clinical Psychiatry, 68, 730–737 Kim, K.Y. & Goldstein, M. Z. (1997). Treating older adults with psychotic symptoms. Psychiatric Services, 48 (9), 1123-1126.
Granholm E., McQuaid J.R., McClure, F.S., Link, P.C., Perivoliotis, D., Gottlieb, J.D., Jeste, D.V. (2007). Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up. Journal of Clinical Psychiatry, 68, 730–737.
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
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
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.
Mueser, K. T., Pratt, S. I., Bartels, S. J., Swain, K., Forester, B., Cather, C., & Feldman, J. (2010). Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness. Journal of Consulting and Clinical Psychology, 78(4), 561–573. https://doi.org/10.1037/a0019629
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Muralidharan, A., Mills, W., Evans, D., Fujii, D., & Molinari, V. (2019). Preparing long-term care staff to meet the needs of aging persons with Serious Mental Illness. Journal of the American Medical Directors Association, 20, 683-688. https://www.jamda.com/article/S1525-8610(19)30305-6/pdf
Muralidharan, A., Mills, W., Evans, D., Fujii, D., & Molinari, V. (2019). Preparing long-term care staff to meet the needs of aging persons with Serious Mental Illness. Journal of the American Medical Directors Association, 20, 683-688. https://www.jamda.com/article/S1525-8610(19)30305-6/pdf
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.
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Street, D., Molinari V., & Cohen, D. (2013). State regulations for nursing home residents with Serious Mental Illness. Community Mental Health Journal, 49(4), 389-395. https://doi.org/10.1007/s10597-012-9527-9
Street, D., Molinari V., & Cohen, D. (2013). State regulations for nursing home residents with Serious Mental Illness. Community Mental Health Journal, 49(4), 389-395. https://doi.org/10.1007/s10597-012-9527-9
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
MEASURES OF SERIOUS MENTAL ILLNESS IN LATER LIFE
Coming soon from the University of Alabama!