Psychogeriatrics A Clinical Guide

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Editors
Nicola Veronese Anna Marseglia
Department of Geriatrics and Internal Department of Neurobiology
Medicine Care Sciences and Society
University of Palermo Division of Clinical Geriatrics
Palermo, Italy Karolinska Institute
Stockholm, Sweden

ISSN 2509-6060     ISSN 2509-6079 (electronic)

Practical Issues in Geriatrics
ISBN 978-3-031-58487-9    ISBN 978-3-031-58488-6 (eBook)
https://doi.org/10.1007/978-3-031-58488-6

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Preface

Welcome to the fascinating world of psychogeriatrics, a discipline devoted to under-

standing the complexity of mental health in aging. This book serves as a compre-
hensive guide to the multifaceted aspects of psychogeriatrics, providing insights
into the psychological, biological, social, and ethical dimensions of mental health in
older adults.
In recent years, the field of psychogeriatrics has gained increasing recognition
and importance owing to the growing population of older adults globally. With
advancements in healthcare and longer life expectancy, the number of older indi-
viduals confronting mental health challenges also is on the rise. Consequently, there
is a pressing need for healthcare professionals, caregivers, researchers, and policy-
makers to deepen their understanding of psychogeriatric conditions, developing and
implementing effective strategies for prevention, diagnosis, treatment, and care.
This book aims, to offer a comprehensive approach to psychogeriatrics, delving
into a number of topics pertinent to mental health and aging. From dementia to
prevalent psychiatric disorders in older adults, each chapter presents valuable
insights and evidence-based recommendations. Furthermore, the book tackles key
psychosocial and ethical aspects of caring for older individuals with mental health
issues, such as the influence of social determinants of health, socio-cultural factors,
and end-of-life care.
The contributors to this book are experts in the field of psychogeriatrics, com-
prising geriatricians, geriatric psychiatrists, neurologists, psychologists with back-
ground in aging and geriatrics, geriatric epidemiologists, and other healthcare
professionals. Their diverse perspectives and wealth of experience enrich the con-
tent of this book, providing readers with a comprehensive and up-to-date resource
for understanding and addressing the mental health needs of older adults.
Throughout the book, emphasis is placed on the importance of interdisciplinary
collaboration and person-centered care in psychogeriatrics. Recognizing the unique
needs and preferences of older individuals, as well as the complex interplay of psy-
chological, social, and environmental factors, is essential for providing effective
and compassionate care.
Beyond healthcare professionals, this book caters to caregivers, family members,
undergraduate and graduate trainees, researchers, and anyone interested in learning
more about psychogeriatrics. By raising awareness and knowledge of mental health

v
vi Preface

issues in older adults, we can work together to promote healthy aging, enhance
quality of life, and ensure dignity and respect for older individuals facing mental
health challenges.
As editors, we are privileged to present this book as a valuable resource for
advancing the field of psychogeriatrics and enhancing the care and support available
to older adults with mental health needs. We hope that readers will find this book
informative, thought-provoking, and ultimately empowering in their efforts to pro-
mote mental well-being and healthy aging in our aging population.
Sincerely

Palermo, Italy Nicola Veronese

Stockholm, Sweden  Anna Marseglia
Contents

1 
Anxiety and Depressive Disorders in Older Adults���������������������������������� 1
Theodore D. Cosco, Megha Goel, Indira Riadi,
Eliza R. Farquharson, Cari Randa, John Pickering,
Jessica Miskiewicz, and John R. Best
2 
Bipolar Disorder in Older People �������������������������������������������������������������� 17
Laura Montejo and Andrea Murru
3 
Alcohol Abuse and Addiction in Older People������������������������������������������ 31
Dorota Religa, Theofanis Tsevis, and Lars-Olof Wahlund
4 
Treatment of Challenging Behavior in Dementia ������������������������������������ 57
Ruslan Leontjevas, Marion Klaver, Martin Smalbrugge,
and Debby L. Gerritsen
5 
General Considerations on Psychopharmacology in Older People�������� 81
Jorge Juri, Alejandro Serra, and Dante Boveris
6 
Loneliness and Psychiatric Disorders in Older Adults���������������������������� 91
Federico Triolo, Linnea Sjöberg, Amaia Calderón-­Larrañaga,
and Lena Dahlberg

vii
Anxiety and Depressive Disorders
in Older Adults 1
Theodore D. Cosco, Megha Goel, Indira Riadi,
Eliza R. Farquharson, Cari Randa, John Pickering,
Jessica Miskiewicz, and John R. Best

1.1 Introduction

In this chapter, we seek to understand the complexities of depression and anxiety

among older adults, a segment of the population frequently marginalized in mental
health discourse. By recognizing that these mental health challenges are not uni-
form across life stages, this chapter specifically focuses on how they manifest,
impact, and are addressed in older adulthood. We begin by dissecting the symptom-
atic profiles of depression and anxiety in this demographic, acknowledging the pos-
sibility that these conditions might represent either a continuation of lifelong mental
health struggles or emerge as new challenges in later life. This distinction is crucial
for developing appropriate therapeutic interventions and support systems.
The chapter further delves into the lived experiences of older adults living with
depression and anxiety, highlighting how these conditions are intricately inter-
twined with the aging process. We explore the unique repercussions these mental
health issues have on the quality of life, daily functioning, and overall well-being of
older individuals. Special attention is given to the role of comorbidities, often preva-
lent in this age-group, which can complicate diagnosis and treatment. The interplay
of physical health issues, such as cognitive decline and chronic illnesses, with

T. D. Cosco (*)
School of Public Policy, Simon Fraser University, Vancouver, BC, Canada
Department of Gerontology, Simon Fraser University, Vancouver, BC, Canada
Oxford Institute of Population Ageing, University of Oxford, Oxford, UK
e-mail: [email protected]
M. Goel · I. Riadi · C. Randa · J. Pickering · J. Miskiewicz · J. R. Best
Department of Gerontology, Simon Fraser University, Vancouver, BC, Canada
E. R. Farquharson
Division of Psychology and Language Sciences, University College London, London, UK

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 1

N. Veronese, A. Marseglia (eds.), Psychogeriatrics, Practical Issues in Geriatrics,
https://doi.org/10.1007/978-3-031-58488-6_1
2 T. D. Cosco et al.

mental health conditions, presents a layered challenge for healthcare providers and
caregivers.
Moreover, we examine the psychological aspects, considering how life transi-
tions, grief, and changes in social roles can contribute to or exacerbate mental health
issues in older adults. The chapter also addresses the critical role of social factors,
including isolation, socioeconomic status, and the evolving dynamics of family sup-
port in the mental health of the elderly. These factors are not only pivotal in under-
standing the prevalence and expression of depression and anxiety but also in shaping
the approaches to treatment and care.
In discussing interventions, the chapter provides a balanced view of both phar-
macological and non-pharmacological strategies. It emphasizes the importance of
tailored treatment plans that consider the unique physiological responses of older
adults to medication, alongside the potential benefits of psychotherapy, digital inter-
ventions, and community support systems. The goal is to present a holistic view of
managing depression and anxiety in older adults, one that goes beyond mere symp-
tom management to enhance overall life satisfaction and well-being.
By the end of this chapter, readers will gain a comprehensive understanding of
the multifaceted nature of depression and anxiety in older adults. The insights
offered aim to foster greater empathy, inform more effective treatment approaches,
and ultimately improve the quality of life for older individuals grappling with these
challenging mental health conditions.

1.2 Depression and Anxiety in the Context of Older Adults

Depression and anxiety are the most common mental health issues older adults may
face in their lifetime. These two mental health problems may be lifelong, or with
onset in older adulthood, with consequent repercussions pertaining to lived experi-
ences and quality of life [1, 2]. Due to the interconnected nature of comorbid depres-
sion and anxiety, it can be difficult to separate onset of one disorder from the other;
however, almost all anxiety disorders appear to show comorbidity with depressive
symptoms of varying severity [1, 3]. The goals of the following section are twofold:
(1) to introduce the symptomatic profiles of depression and anxiety in the context of
older adults and (2) to explore the complexities of the lived experiences of older
adults with depression and anxiety and the resulting multiple jeopardies when bio-
logical, psychological, and social factors interact.

1.2.1 Depression and Aging

Depression is not a normal part of the aging process; however, older adults are at an
increased risk of developing depression over time. Although depression symptoms
present similarly in older adults as with younger cohorts, older adults have the
added burden of comorbid medical conditions including cognitive impairment and
often receive ineffective treatment or symptoms even remain undetected [4].
1 Anxiety and Depressive Disorders in Older Adults 3

Depressive symptoms accompany and interact with a wide array of experiences and
comorbidities more common for older adults, so the indicators are easy to overlook
and remain untreated, perpetuating negative perceptions of health and perceived
futility of accessing health care services [5]. The bidirectional nature of depression
and comorbid health conditions can occlude developing a holistic treatment plan.
Major Depressive Disorder (MDD) and Persistent Depressive Disorder (PDD) are
the two most common depressive disorders affecting older adults [6]. For more than
half of people living with depression, onset of depressive symptoms is reported in
older adulthood [7]. Although older adults appear to have lower prevalence of
depression than younger cohorts, this can be explained with the survivorship bias,
wherein those who are more severely affected die earlier. Even below diagnosable
thresholds for Major Depressive Disorder (MDD), 10% to 15% of older adults
experience clinically significant depressive symptoms [4, 8]. In community-­
dwelling older adults aged 65 and over, MDD ranges in prevalence 1–5% interna-
tionally, with most countries trending toward the lower range [7, 9].

1.2.2 Anxiety and Aging

The body of research is less robust exploring the symptoms, expression, and exter-
nal factors characterizing anxiety disorders in older adults. As an explanation to the
vast underreporting of anxiety disorders in older adults, these older adults may have
withdrawn socially or are unable to cope with the multiple jeopardies of illnesses
affecting all facets of their health and participation, especially to seek out and com-
plete research opportunities. Anxiety disorders pertaining to older adults include
specific phobias, social anxiety disorder, generalized anxiety disorder (GAD), panic
disorder, and agoraphobia [6]. Prevalence of anxiety disorders in older adults is
estimated to range from 3.2% to 14.2% [3, 6, 10]. Older adults living with anxiety
later in life must overcome the detrimental effects of increased loneliness and isola-
tion, decreased physical activity and associated health outcomes, and low satisfac-
tion with perceived quality of life [11, 12]. Cognitive symptoms of anxiety like
worry can exacerbate medical conditions and tax already frail physical defences.

1.3 Multiple Jeopardies

Aging is a multifaceted and complex human experience influenced by biological,

psychological, and social factors, further complicated by mental health issues across
the lifespan. It is important to note that adults living with chronic mental health
issues, also referred to as serious persistent mental illness (SPMI), will have faced
social exclusion, housing insecurity, and limited income potentially contributing to
a lower subjective appraisal of the value of their life. Multimorbidities and similari-
ties in expression of symptom present a difficult task for geriatric healthcare provid-
ers in making a differential diagnosis for appropriate treatment.
4 T. D. Cosco et al.

1.3.1 Biological Factors

Biological aging refers to natural, irreversible, and progressive age-related changes

in metabolic chemical processes within the human body, diminishing regeneration
at the cellular level and resulting in structural and functional changes [13]. Biological
factors affect the location of interactions between older adults and kin or service
providers as physical condition might dictate an older adult’s location in the com-
munity, hospital, or long-term care [13]. Depression increases the risk of death in
older adults living in long-term care 2–3 times more than those living in the com-
munity and exacerbates physical and cognitive decline [14]. Fiske et al. [7] suggest
that insomnia is a ubiquitous risk factor for depression in older adults disrupting
participation in daily activities and possibly contributing to negative thoughts about
oneself. [3, 7]. Fostering understanding of psychiatric comorbidity of depression
and anxiety is one option to engage interdisciplinary approaches to care for older
adults [3]. The role of family history is less well understood for late onset depres-
sion and anxiety [3].

1.3.2 Psychological Factors

Psychological factors of aging include attitudes, awareness of, and adaptability to

the aging process embedded within cultural norms [13]. Personality and individual
coping styles contribute to negative thought patterns and pathways to accessing
social support [3]. Older adults are more likely to experience transitions and losses,
including grief and bereavement, in combination with other risk factors such as
neuroticism as an enduring personality trait or a high medical burden with comorbid
illnesses or caregiver stress as well as gender differences and hospitalization. Older
adults are more likely to successfully take their own lives in association with depres-
sion than younger adults, due in part to increased baseline frailty higher than in
younger adults and more closely associated with depression [6, 7]. In a systematic
review, Beghi et al. [15] outline that older adults, especially white males over the
age of 65, are at the highest risk for suicide due to the culmination of risk factors
ranging from mental health issues, stress, bereavement, poor health, and isolation.
Suicidal ideation can be challenging to identify for older adults, and better treatment
of clinical depression for this population is an area in need of further research [16].

1.3.3 Social Factors

Marital status, income level, symptom expression, interpretation of illness, and

response to disorder are connected to gender, with women developing depression,
anxiety, or both later in life outnumbering men 2:1 [3, 7]. In addition, depression
and anxiety may be experienced or expressed differently by varying ethnic groups
1 Anxiety and Depressive Disorders in Older Adults 5

but is need of further study for comparative representation. Globalization has dra-
matically changed family structure and expectations of intergenerational family
care [17, 18]. Community support is a keystone for community-dwelling older
adults because much of this population experiences a shrinking world with mobility,
participation, and cognitive changes [17, 19]. In both developed and developing
countries, older adults living in impoverished, isolated communities with limited
social support, especially when children have moved away, experience the worst
mental health outcomes [19–21]. Inequalities in housing, social support, income,
and access to healthcare contribute to social determinants of health affecting quality
of life and positive coping mechanisms influencing life satisfaction for older adults
living with depression and anxiety [22].

1.4 Interventions for Depression and Anxiety

1.4.1 Pharmacological Interventions

1.4.1.1 Depression
For the initial treatment of depression, healthcare professionals may suggest a com-
bination of antidepressant medication and psychotherapy. Well-designed studies
have shown that combination treatment is more effective than either treatment on its
own. Nevertheless, either treatment can also be given alone, as studies have also
shown that each is effective and comparable to the other.
When selecting an antidepressant, it is important to consider the elderly patient’s
previous response to treatment, the type of depression, the patient’s other medical
problems, the patient’s other medications, and the potential risk of overdose.
Antidepressants are effective in treating depression in the face of medical illnesses,
although caution is required so that antidepressant therapy does not worsen the
medical condition or cause adverse events. For example, dementia, cardiovascular
problems, diabetes, and Parkinson disease, which are common in the elderly, can
worsen with highly anticholinergic drugs. Such drugs can cause postural hypoten-
sion and cardiac conduction abnormalities. It is also important to minimize drug–
drug interactions, especially given the number of medications elderly patients are
often taking. Tricyclic antidepressants are lethal in overdose and are avoided for
this reason.
All the medications within a particular class are chemically related and function
in a similar way. The more commonly used medications are from the following
classes:

• Selective serotonin reuptake inhibitors (SSRIs) (Box 1.1)

• Serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Atypical antidepressants
• Serotonin modulators
6 T. D. Cosco et al.

Box 1.1 SSRIs

Among the different antidepressants, SSRIs offer as much benefit as other
medications with the least amount of risk in terms of safety and side effects.
They are the most widely prescribed class of antidepressants. SSRIs—such as
Lexapro, Celexa, Zoloft, Paxil and Prozac—are believed to alleviate symp-
toms of depression, excessive worry, and compulsivity by acting upon the
brain’s chemistry—specifically by blocking the breakdown and reabsorption
of the neurotransmitter serotonin in the spaces between neurons. This selec-
tive reuptake inhibition causes serotonin levels to rise, promoting neuronal
firing in circuits of the brain associated with mood and anxiety. SSRIs are all
relatively safe in the elderly. They have lower anticholinergic effects than
older antidepressants and are thus well tolerated by patients with cardiovascu-
lar disease. The alternatives to SSRIs include other second-generation antide-
pressants, namely serotonin-norepinephrine reuptake inhibitors, atypical
antidepressants, and serotonin modulators.

Since all the second-generation antidepressants are roughly equivalent in terms of

efficacy, health care providers select them based on other factors, such as:

• Each medication’s safety and side effect profile

• The person’s specific depressive symptoms
• Comorbid psychiatric and general medical illnesses
• The other medications the person is taking and whether they could interact with
the chosen antidepressant
• Each medication’s ease of use (for example, based on the number of pills the
person must take each day)
• What the person prefers
• The cost of a medication and whether it is covered by insurance
• The person’s previous responses to antidepressants (during past bouts of
depression)

For example, for people who have trouble sleeping, health care providers often
favor antidepressants known to promote sleep, such as mirtazapine. Similarly, for
people who want to avoid the sexual side effects caused by many antidepressants,
health care providers might favor bupropion, which is less likely to cause these side
effects.

1.4.1.2 Anxiety
When treating anxiety disorders, antidepressants, particularly the SSRIs and some
SNRIs (serotonin-norepinephrine reuptake inhibitors), have been shown to be
effective.
Other anti-anxiety drugs include the benzodiazepines, such as as alprazolam
(Xanax), diazepam (Valium), buspirone (Buspar), and lorazepam (Ativan). These
1 Anxiety and Depressive Disorders in Older Adults 7

drugs do carry a risk of addiction or tolerance (meaning that higher and higher doses
become necessary to achieve the same effect), so they are not as desirable for long-
term use. Other possible side effects include drowsiness, poor concentration, and
irritability. Some anticonvulsant drugs (such as gabapentin [Neurontin] or pregaba-
lin [Lyrica]), some blood pressure medications (such as propranolol), and some
atypical antipsychotics (such as aripiprazole or quetiapine or Seroquel) are also
occasionally used “off label” to treat anxiety symptoms or disorders.

1.4.1.3 Notable Points on Pharmacological Interventions

Dose—In general, health care providers tend to start their patients on low doses and
slowly increase them as necessary. Once an antidepressant is selected for an older
patient, the starting dose should be half that prescribed for a younger adult in order
to minimize side effects. Increased side effects from antidepressant use in the elderly
are thought to be due to changes in hepatic metabolism with aging, concurrent med-
ical conditions, and drug–drug interactions. The best effects are often seen when
doses are raised but still well tolerated.
How long before antidepressants take effect?—Antidepressants often take time
to work, but many people start to feel better within 1–2 weeks. In fact, the people
who see some benefit early on after starting an antidepressant appear to be the ones
most likely to completely recover. That being said, it can take 6–12 weeks to see the
full effect of an antidepressant, so health care providers may wait that long to make
a final decision if a medication will be effective enough. If there is no significant
improvement after 2–4 weeks on an average therapeutic dose, further increases
should be made until there is either a clinical improvement, intolerable side effects,
or the maximum suggested dose is reached. Thus, it is important to schedule regular
follow-up visits to monitor treatment response while assessing for side effects and
titrating accordingly.

1.4.2 Non-pharmacological interventions

1.4.2.1 Psychotherapy
All forms of psychotherapy include support from a professional who is focused on
helping you to make positive psychological changes. There are many specific types
of psychotherapy that are used to treat depression. Each works in a slightly different
way, but all have been proven to help improve the symptoms of depression; many
psychotherapists use a combination of techniques when working with clients (see
Box 1.2).
Many forms of psychotherapy have been shown to be effective in the treatment
of late-life depression, with similar efficacy rates achieved as found for younger and
mid-life adults. The strongest evidence base exists for Problem Solving Therapy
(PST) and Cognitive Behavior Therapy (CBT), with some evidence for Interpersonal
Psychotherapy (IPT). A recent meta-analysis of psychotherapy for older adults
found that, while the magnitude of effect depended on the type of control condition
used, psychotherapy was overall effective in reducing depression. Increasing the
8 T. D. Cosco et al.

availability of psychotherapy for older adults is especially crucial given consistent

evidence that older adults prefer psychotherapy over medication to treat their
depression. Despite these preferences, however, older adults rarely receive psycho-
therapy for depression due to a combination of access, availability, clinician work-
force limitations, and individual-level factors like stigma.
Psychotherapy, as a non-pharmacological approach, plays a crucial role in treat-
ing depression and anxiety, offering professional support to facilitate positive psy-
chological changes [23]. This form of treatment has shown to be equally effective in
both older adults and younger populations, underscoring its versatility and broad
applicability across different age-groups [24].
In the context of evidence-based therapeutic approaches for older populations,
Cognitive Behavioral Therapies (CBTs), Problem Solving Therapy (PST), and
Interpersonal Psychotherapy (IPT) stand out for their effectiveness. CBTs are par-
ticularly renowned for their well-documented success in treating a broad spectrum
of mental and behavioral disorders. Additionally, PST offers a structured approach
to problem-solving as a coping mechanism, while IPT focuses on improving inter-
personal relationships. Despite the established efficacy of evidence-based therapy
for treating depression and anxiety among older adults, research indicates that a
relatively small proportion of this demographic actually pursue or have access to
such therapy [25, 26].

Box 1.2 Forms of Psychotherapy

Cognitive and Behavioral Therapies (CBTs): CBT focuses on the intercon-
nectedness of thoughts, feelings, and behaviors. The assumption is that nega-
tive thoughts and beliefs lead to emotional distress and maladaptive behavior.
CBT posits that challenging detrimental thoughts and beliefs leads to changes
in affect and behavior.
Behavioral Therapy (BT): A component of CBT primarily focuses on
behavioral modification without the direct emphasis on cognition. This
approach can be particularly suitable for older adults who have diminished
cognitive abilities. BT focuses on enhancing positive behaviors, reducing
avoidance patterns, and minimizing engagement in negative activities. It
involves behavioral monitoring, where clients identify actions that lead to
negative feelings and replace them with more enjoyable activities. Adjusting
for any sensory or physical limitations to ensure full participation is essential
in delivering effective BT, particularly for older adults.
Problem-Solving Therapy (PST): A structured approach that uses problem-­
solving as an active coping strategy. It consists of four stages: identifying the
problem exacerbating depression, generating a list of potential solutions,
evaluating these solutions and their consequences, and finally, implementing
and assessing the effectiveness of the chosen solution. This approach is par-
ticularly beneficial for managing depressive symptoms, encouraging clients
to actively tackle issues impacting their mental health.
1 Anxiety and Depressive Disorders in Older Adults 9

Interpersonal Psychotherapy (IPT): The focus is on the client’s relation-

ships and social interactions. This therapy helps patients understand and
improve their interactions with others, enhancing their social roles and
relationships.
• CBT—In CBT, the patient works with a therapist to identify and reshape
the thought and behavior patterns that contribute to their depression or
anxiety.
• IPT—In interpersonal psychotherapy, the patient will focus on their rela-
tionships, the interactions with people in their lives, and the different social
roles they play. In this form of psychotherapy, the patient can learn new
ways to interact with others and improve existing and future
relationships.
• PST—In problem-solving therapy, the patient takes a practical approach to
the problem and decides on ways to solve them. For example, for a patient
struggling with depression/anxiety due to financial struggles, they may
work with a therapist to develop action steps to getting a job or budgeting.

1.4.2.2 Clinician Guided Self-help

For many older adults facing anxiety and mood disorders, a critical yet often over-
looked step is recognizing their need for mental health care, which is vital for
accessing necessary treatments and support. Enhanced efforts to educate both older
adults and health professionals about the benefits and effectiveness of psychological
therapies are essential to lower the barriers to seeking mental health care in this
demographic [27].
For some older adults, engaging with a health professional might not be the most
comfortable method to tackle their mental health issues. Instead of attending formal
therapy sessions, they may opt to work on their own with limited guidance from a
health care provider. Clinician guided self-help involves the use of workbooks
(hardcopy, compact disc, or internet-based), audiotapes, or videotapes to monitor
symptoms, changes in mood, and performing actions that can alleviate their depres-
sion/anxiety. People who choose this approach check in periodically with their
health care provider but the interactions are much more brief and infrequent com-
pared with formal therapy. Guided self-help can be a good choice for people who
have mild depression and have no severe thoughts of self-harm or suicide.

1.4.2.3 Digital Mental Health Interventions

Digital mental health interventions are promising in their ability to provide research-
ers, mental health professionals, clinicians, and patients with personalized tools for
assessing their behavior and seeking consultation, treatment, and peer support. A
recent systematic review that examined existing randomized controlled trial studies
on digital mental health interventions for older adults determined four factors that
contributed to the success of digital mental health interventions: (1) ease of use; (2)
10 T. D. Cosco et al.

opportunities for social interactions; (3) having human support; and (4) having the
digital mental health interventions tailored to the participants’ needs.
Online therapy is the communication and relationship between clients and their
mental health provider that is facilitated through online technology such as emails,
videoconferencing, text messaging, and chat rooms [28]. For older populations,
online therapy can offer significant logistical advantages, particularly in reducing
the need for travel and increasing accessibility for those who might be far from
treatment centers, face physical challenges in attending sessions, or have behavioral
conditions that make traditional, in-person therapy less feasible [29]. Moreover,
online therapy is recognized for its cost-effectiveness and ability to alleviate issues
like long waiting lists [30].
Adding to the spectrum of digital mental health solutions, mental health apps are
becoming increasingly crucial, especially for rural populations. These apps enhance
the accessibility of care, allowing individuals to receive support anytime and any-
where, which is particularly beneficial in areas with limited mental health services
[31]. The anonymity provided by these apps helps reduce the stigma often associated
with seeking mental health care, making them a discreet option for those hesitant to
seek traditional in-person therapy [31]. Furthermore, the affordability of these apps
makes mental health care more accessible, addressing the economic barriers.
Many of these mobile applications are relatively easy to use and can be accessi-
ble by even older adults who are not technologically savvy. Older adults may have
a preference to talk to a professional via phone call instead of through chat and an
app that allows the user to choose the mode of communication can benefit a wider
range of population. Examples of these smartphone applications are BetterHelp and
Talkspace. The therapists on these therapy apps often have specific training in areas
such as cognitive behavioral therapy, existential-humanistic approaches, dialectical
behavioral therapy, psychodynamic, and mindfulness. The users of these apps can
call, send text, video, and audio messages to their respected therapist at any time
(https://www.betterhelp.com/; https://try.talkspace.com/).
Online CBT (iCBT): The effectiveness of Internet-delivered Cognitive
Behavioral Therapy (iCBT) in alleviating symptoms of anxiety and depression
among older adults has been well demonstrated in various studies [32]. In a study
focusing on adults over 60 with symptoms of depression, iCBT interventions dem-
onstrated significant improvements in reducing symptoms of both depression and
anxiety [33]. These positive outcomes were not only observed post-treatment but
also maintained at follow-up assessments conducted at 3 and 12 months, indicating
the sustained effectiveness of the iCBT approach in this age-group [33].
Apps like Sanvello and MindShift provide web-delivered CBT for users with
mild to moderate anxiety and depression. In a randomized study of 500 adults with
mild to moderate anxiety and depression, online CBT apps like Sanvello were
shown to decrease symptoms. In apps like Sanvello and Mindshift, there are also
online communities that allow users to connect with others anonymously where
people can share advice, ask questions, or talk to others who understand.
Online cognitive training has been shown to alleviate depressive and anxiety
symptoms. An existing study used an online speed of processing training program
1 Anxiety and Depressive Disorders in Older Adults 11

on a group of older adults with early Alzheimer’s disease. Their findings indicated
that, through using the Geriatric Depression Scale, the training resulted in signifi-
cant improvements in those who received the cognitive training compared with
those in the waiting list group. Another recent online cognitive training study looked
at a different cognitive training digital mental health intervention, recognized as a
neuroplasticity-based computerized cognitive remediation, designed to target the
cognitive control functions of older adults with late-life depression. The results
showed that neuroplasticity-based computerized cognitive remediation induced
remission in significant portions of the group
A study examined the effects of online Cognitive Training (CT) for older adults
which reveals that such interventions can substantially improve cognitive abilities
and the capacity to perform daily activities [34]. Notably, reasoning capabilities
showed marked improvements, demonstrating the effectiveness of these online
interventions. These advancements were on par with those achieved through tradi-
tional in-person training methods. This underscores the promise of online CT as a
viable public health strategy, not only enhancing cognitive function in the elderly
but also potentially reducing dementia risks.

1.4.2.4 Social Work and Mental Health Interventions

Social work approaches to treating mental health issues in older adults emphasize
the influence of biological, psychological, and social factors. Social workers are
unique among healthcare providers in that they are trained to work with the com-
plexities of each individual’s situation within the context of their environment [35].
Utilizing their understanding of systems theory and human behavior, social workers
assist older adults in adapting to the changes that accompany the aging process,
including managing loss and grief, addressing stress or worry, and rebuilding social
networks [36]. The literature in aging research extensively documents the positive
influence of social support in alleviating depression and nurturing a sense of pur-
pose among older adults [37, 38]. Furthermore, sense of purpose, a central compo-
nent of psychological well-being, has been linked to reduced risk for social anxiety,
fewer depressive symptoms, and acts as a protective factor against depression-­
related cognitive decline in older adults [39–41].
For some diverse older adults, disruptions in family support and social harmony
are identified as contributors to mental illness such as depression [42]. Geriatric
social workers recognize the importance of involving family members in psychoso-
cial and cognitive assessments and interventions. They help older adults and their
support systems navigate complex behavioral health systems, coordinate care, and
monitor service efficacy to provide comprehensive support [35]. The empathetic
and holistic approach of social workers positions them as essential healthcare pro-
viders for older adults facing depression and anxiety, offering emotional support,
disseminating information, facilitating connections, and empowering individuals.
Moreover, incorporating the needs and concerns of the older person in mental health
care decision-making is central to client-centered social work practice, fostering
strong therapeutic relationships that are key predictors for help-seeking, treatment
engagement, and adherence [43].
12 T. D. Cosco et al.

Geriatric social work encompasses various roles, ranging from acute healthcare
to supportive social care [44]. Social workers contribute to multidisciplinary health-
care teams, engage in community-based case management, and provide clinical ser-
vices such as crisis intervention and counseling [35]. Additionally, social workers
conduct functional assessments of older people’s everyday competence, positioning
them well to observe nuanced changes in daily mental and cognitive functioning
[35]. Recognizing symptoms based on changes in daily habits enables social work-
ers to intervene early [45]. Addressing physical limitations and long-term care
needs arising from depression and anxiety symptoms is another crucial aspect of
geriatric social work, involving connecting older adults to home health services for
their medical, functional, and social well-being. Supportive care becomes espe-
cially beneficial for older adults with anxiety disorders and cognitive impairments
that may lead to isolation.
Social workers play a pivotal role in addressing challenges to the quality of life
of older adults with mental health issues through direct practice as well as meso/
macro level work. They advocate for social justice, human rights, and equal access
to mental health services throughout old age [46].

1.5 Summary

This chapter provides an exploration of depression and anxiety among older adults,
shedding light on the multifaceted nature of these mental health challenges. It delves
into the symptomatic profiles, the impact of comorbidities, and the unique lived
experiences of older individuals grappling with these conditions. The discussion
underscores the importance of recognizing the distinct ways in which depression
and anxiety manifest in older adulthood, influenced by a complex interplay of bio-
logical, psychological, and social factors. The chapter emphasizes the critical need
for tailored interventions, advocating for a holistic approach that encompasses both
pharmacological and non-pharmacological strategies to address the specific needs
of this demographic. By highlighting the role of psychotherapy, digital interven-
tions, and the invaluable support of social work, the chapter aims to foster a deeper
understanding of the challenges faced by older adults with depression and anxiety.
Ultimately, it calls for greater empathy, informed treatment approaches, and
enhanced support systems to improve the quality of life for older individuals facing
these profound mental health issues, advocating for a society that better accommo-
dates the mental health needs of its aging population.

References
1. Cameron OG. Understanding comorbid depression and anxiety. Psychiatric Times.
2007;24(14):51. https://www.psychiatrictimes.com/view/understanding-­comorbid-­
depression-­and-­anxiety. Accessed 24 Aug 2022.
2. Cameron OG, Abelson JL, Young EA. Anxious and depressive disorders and their comorbidity:
effect on central nervous system noradrenergic function. Biol Psychiatry. 2004;56(11):875–83.
https://doi.org/10.1016/j.biopsych.2004.08.007.