Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by developmentally inappropriate levels of hyperactivity, impulsivity, and/or inattention. ADHD is chronic, may persist into adulthood, and is associated with impairment in social and academic/work domains across the lifespan. Children and adolescents with ADHD often present with executive function deficits and emotion dysregulation, and these deficits may increase impairment and risk for co-occurring disorders. The etiology of ADHD is not yet understood, though research suggests that biological and environmental factors (e.g., family, community) contribute to its development and course. It should be noted that ADHD commonly co-occurs with additional psychiatric disorders, such as oppositional defiant disorder (ODD), conduct disorder (CD), and major depressive disorder. Evidence-based assessment of ADHD requires information from multiple informants using multiple assessment methods to determine the presence of ADHD symptoms across settings and any co-occurring disorders. The evidence-based treatment options for ADHD are manifold. Pharmacotherapy for ADHD is common, although numerous behavioral interventions are also effective. Stimulant medications are commonly prescribed and are typically effective in ameliorating core ADHD symptoms. There is also evidence that the nonstimulant medication atomoxetine substantially decreases the symptoms of ADHD. Importantly, medication therapy works to reduce symptoms but typically does not alleviate the impairments associated with the disorder. Combined medication and behavioral interventions are more likely to reduce impairments and normalize behavior.
Kelsey E. Woods, Christina M. Danko, and Andrea Chronis-Tuscano
Jonathan S. Gooblar and Sherry A. Beaudreau
Anxiety disorders are among the most prevalent and understudied mental health problems in late life. Specific phobia, social anxiety disorder, and generalized anxiety disorder are the most prevalent anxiety disorders in older adults among the 11 disorders identified by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Anxiety disorders lead to significant functional burdens and interface with physical health problems and cognitive impairment, concerns frequently experienced in adults over age 65. Additional contextual factors should be considered when assessing and treating late-life anxiety, including the effects of polypharmacy, other mental health conditions, role changes, and societal attitudes toward aging. The relationship between anxiety and physical health problems in older adults can be causal or contextual, and can involve poorer estimates of subjective health and lower ratings of functioning. These factors present unique challenges to the detection, conceptualization, and treatment of late-life anxiety, including the tendency for older adults to focus on somatic symptoms and the potential for long-term behaviors that can mask distress such as substance use. Researchers are increasingly incorporating a gerodiversity framework to understand the contributions of cultural, individual, and other group differences that may affect the presentation of anxiety symptoms and disorders. Older adults in general are less likely to be treated for anxiety disorders, and intersecting individual and group differences likely further affect how anxiety disorders are perceived by healthcare providers. Cognitive behavioral therapy and its variants have the most empirical support for treatment. Newer evidence lends support to acceptance and commitment therapy and problem-solving therapy, which tend to address some of the contextual factors that may be important in treatment.
M. Lindsey Jacobs and Patricia M. Bamonti
The field of geropsychology has grown worldwide since the 1990s, particularly in the United States. In the early 21st century, professional geropsychology was recognized by the American Psychological Association as a clinical specialty. Despite this growth, there is a shortage of practicing psychologists proficient in geropsychology to meet the mental health needs of older adults. Moreover, the need for psychologists with geriatric training is continuing to grow as healthcare increasingly shifts to integrated care, creating a demand for psychologists in clinical settings such as nursing homes, hospice and palliative care, primary care, and home-based primary care. The widening gap between supply and demand requires strategic recruitment and educational initiatives to grow the number of providers with competency in working with older adults. Recruitment strategies emphasize increasing supply by “priming the pipeline” through the creation of early exposure opportunities at the secondary, undergraduate, and graduate school level, strategic recruitment of underrepresented students, and expanding financial incentives for practice. Training and education in geropsychology have advanced considerably. The Pikes Peak Model for Professional Geropsychology Training provides the structure to gauge competency development. A framework for obtaining competency at the generalist, generalist with proficiency, and specialist levels has been created. In future years, there will be greater demand for post-licensure training in geropsychology, and geropsychologists will increasingly function as clinical educators. Technological advances will play a vital role in disseminating geropsychology education to generalist providers and related disciplines interested in gaining geropsychology exposure.
Lydia K. Manning, Lauren M. Bouchard, and James L. Flanagan
There is a great deal of concern about the increasing number of older adults who suffer from chronic disease. These conditions result in persistent health consequences and have an ongoing and long-term negative impact on people and their quality of life. Furthermore, the probability that a person will experience the onset of multiple chronic conditions, known as comorbidities, increases with age. Despite the prevalence of comorbidity in later life, scant research exists regarding specific patterns of disease and the co-occurrence and complex interactions of the chronic conditions most closely associated with aging. It is important to review the body of literature on comorbidities associated with physical and psychiatric syndromes in later life to gain an overview of some of the most commonly seen disorders in older adults: hypertension, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, arthritis, depression, and dementia. Specific patterns of disease and the co-occurrence and complex interactions of chronic conditions in later life are explored. In conclusion, we consider the need for a more informed understanding of comorbidity, as well as a related plan for addressing it.
Deborah M. Capaldi, David C. R. Kerr, and Stacey S. Tiberio
Intergenerational studies are key to informing research, preventive intervention, and policy regarding family influences on healthy development and maladjustment. Continuities in family socialization and contextual risks across generations, as well as genetic factors, are associated with the development of psychopathology—including externalizing problems in children—and with intergenerational associations in the use of marijuana, alcohol, tobacco, and other drugs; these continuities are reflected in the low-to-moderate associations generally found in prospective studies. Until recent years, estimates of intergenerational continuities in problem behaviors and the processes explaining such associations (e.g., parenting behaviors) have been based largely on retrospective reports by adults about their own parents’ behaviors. Now there are some long-term prospective studies spanning as many as 30 years that can assess linkages between behaviors in one generation and the next. Whereas such studies have considerable design and implementation challenges, and are very expensive, it is of critical importance to examine the magnitude of associations of behaviors across generations. For example, a modest association across generations suggests either that genetic factors have a limited influence on that behavior or that they are subject to considerable moderation by environmental factors. These prospective studies relate to theoretical developments regarding intergenerational influences that are reviewed—for example, individual differences in genetic sensitivity to environmental influences. The theoretical approach employed in the Oregon Youth Study—Three Generation Study is a Dynamic Developmental Systems (DDS) model of continuous feedback across systems throughout development. A new hypothesis encompassed by DDS is developmental congruence of intergenerational associations in problem behaviors. As used in geometry, congruence refers to figures of a similar shape and size. This term has been adapted to refer to the expectation that ages of onset and patterns of growth in key behaviors will show similarity across generations. This is based on the theory that genetic and temperamental factors increase an individual’s risk when these factors are expressed at sensitive developmental periods. Thus, the timing of these manifestations (e.g., susceptibility to deviant peer influences) is expected to be similar across generations. Developmental similarity is also likely due to continuities in social-risk context and family mechanisms, such as parenting.
Simon J. Haines, Jill Talley Shelton, Julie D. Henry, Gill Terrett, Thomas Vorwerk, and Peter G. Rendell
Tasks that involve remembering to carry out future intentions (such as remembering to attend an appointment), and the cognitive processes that enable the completion of such tasks (such as planning), are referred to as prospective memory (PM). PM is important for promoting quality of life across many domains. For instance, failures in remembering to meet social commitments are linked to social isolation, whereas failures in remembering to fulfill occupational goals are linked to poorer vocational outcomes. Declines in PM functioning are of particular concern for older adults because of the strong links between PM and functional capacity. The relationship between age and PM appears to be complex, dependent on many factors. While some aspects of PM appear to hold up relatively well in late adulthood, others appear to show consistent age-related decline. Variability in age differences appears to partially reflect the fact that there are diverse types of PM tasks, which impose demands on a range of cognitive processes that are differentially affected by aging. Specifically, the level and type of environmental support associated with different PM task types appears to be a meaningful determinant of age-related effects. Given the worldwide changing age demographics, the interest in age-related effects on PM will likely intensify, and a primary focus will be how to optimize and maintain PM capacity for this population. This is already reflected in the increasing research on interventions focused on enhancing PM capacity in late adulthood, and points to important future directions in this area of study.
Nancy A. Pachana, Nicola W. Burton, Deirdre McLaughlin, and Colin A. Depp
Research on healthy aging has begun to address mental health issues in later life. Despite the debates about exactly what constitutes healthy aging and which are the most useful or valid determinants of this construct to study, there is substantial evidence for several determinants of successful aging, including physical activity, cognitive stimulation, and social networks. All three of these determinants support mental health, including cognition, in later life. Resilience is another construct that plays an important role in healthy aging, but it has not received as much research attention at the end of life as in earlier periods. Factors that reduce the risk of mental distress or promote resilience with respect to mental health in the face of challenges in later life remain fruitful areas for further investigations.
Stephen J. Bright
In the 21st century, we have seen a significant increase in the use of alcohol and other drugs (AODs) among older adults in most first world countries. In addition, people are living longer. Consequently, the number of older adults at risk of experiencing alcohol-related harm and substance use disorders (SUDs) is rising. Between 1992 and 2010, men in the United Kingdom aged 65 years or older had increased their drinking from an average 77.6 grams to 97.6 grams per week. Data from Australia show a 17% increase in risky drinking among those 60–69 between 2007 and 2016. Among Australians aged 60 or older, there was a 280% increase in recent cannabis use from 2001 to 2016. In the United States, rates of older people seeking treatment for cocaine, heroin, and methamphetamine have doubled in the past 10 years. This trend is expected to continue. Despite these alarming statistics, this population has been deemed “hidden,” as older adults often do not present to treatment with the SUD as a primary concern, and many healthcare professionals do not adequately screen for AOD use. With age, changes in physiology impact the way we metabolize alcohol and increase the subjective effects of alcohol. In addition, older adults are prone to increased use of medications and medical comorbidities. As such, drinking patterns that previously would have not been considered hazardous can become dangerous without any increase in alcohol consumption. This highlights the need for age-specific screening of all older patients within all healthcare settings. The etiology of AOD-related issues among older adults can be different from that of younger adults. For example, as a result of issues more common as one ages (e.g., loss and grief, identity crisis, and boredom), there is a distinct cohort of older adults who develop SUDs later in life despite no history of previous problematic AOD use. For some older adults who might have experimented with drugs in their youth, these age-specific issues precipitate the onset of a SUD. Meanwhile, there is a larger cohort of older adults with an extensive history of SUDs. Consequently, assessments need to be tailored to explore the issues that are unique to older adults who use AODs and can inform the development of age-specific formulations and treatment plans. In doing so, individualized treatments can be delivered to meet the needs of older adults. Such treatments must be tailored to address issues associated with aging (e.g., reduced mobility) and may require multidisciplinary input from medical practitioners and occupational therapists.
Kim Van Orden, Caroline Silva, and Yeates Conwell
Suicide in later life is a significant public health problem around the world—a problem that will increase in magnitude in the coming years with the impact of population aging. Adults age 70 and older have higher suicide rates than younger groups worldwide in both lower-income and higher-income countries. While suicide rates tend to increase with age, suicide in later life is not an expected or normative response to stressors that accompany the aging process. Instead, a constellation of risk factors places an older adult at elevated risk for suicide. These factors can be remembered as the Five D’s: psychiatric illness (primarily depression); functional impairment (also called disability, often associated with dependency on others); physical illness (particularly multiple comorbid diseases); social disconnectedness (including social isolation, loneliness, family conflict, and feeling like a burden); and access to lethal (deadly) means. The greatest risk occurs when multiple domains of risk converge in a given individual. Approaches to prevention can address the Five D’s. Given that older adults are reluctant to seek out mental healthcare and that standard primary care practice cannot easily provide it, models of primary care-based integrated care management for mental disorders, including in older adulthood, have been developed, rigorously tested, and widely disseminated. These models play an important role in suicide prevention by integrating treatment for physical and mental illness. Upstream, selective prevention strategies that target disconnectedness—such as engaging older adults as volunteers—may serve to reduce disconnectedness and thereby reduce suicide risk. Universal prevention strategies that involve growing the geriatric workforce may address disability by increasing older adults’ access to medical and social service providers with expertise in improving physical, cognitive, and social functioning, as well as improving quality of life. Addressing ageism and building age-friendly communities that use strategies to integrate older adults into society and promote social participation hold promise as universal prevention strategies. Ultimately, effective suicide prevention strategies for older adults must focus on improving quality of life as well as preventing suicide: strategies such as psychotherapy and medication for psychiatric disorders must be supplemented by prevention strategies for older adults give at all ages in addition to treating psychiatric disorders and suicidal thoughts is needed to address the problem of suicide in later life.