Introduction – The Importance of a Course on Aging

Aging Population

Based on latest US census data, adults aged 65 and older make up 55.8 million and comprise 16.8% of the total population in the United States (U.S. Census Bureau, 2023). This group of individuals grew almost five times faster than the total population during the hundred-year period from 1920 to 2020 (Caplan, 2023). This rate of growth is not unique to just the United States, as every country in the world is experiencing growth in the proportion of older adults in the population (World Health Organization [WHO], 2024). By 2030, 1 in 6 people in the world will be aged 60 years or over and by 2050 the world’s population of people aged 60 years and older will likely reach 2.1 billion (WHO, 2024). Between 2020 and 2050, the number of adults aged 80 years or older is expected to triple (WHO, 2024). For this course on aging, an older person is referred to as a person 65 years or older (NIH, 2025).

With an aging population, many of the individuals you serve will increasingly be older adults. While mental illness is not a normative aspect of aging – only about 14% of adults aged 70+ have a diagnosed mental health condition (WHO, 2023) – this age group encounters distinct biological, psychological, and social factors that warrant careful consideration in clinical practice. In later life, mental health is influenced not only by current physical and social conditions but also by the accumulated effects of past experiences and age-specific stressors. Challenges such as adversity, changes in physical capacity, and declining functional abilities can contribute to psychological distress. Older adults often face difficult transitions, including bereavement, reduced income, and navigating a sense of purpose following retirement. Despite their valuable contributions to society, many older adults encounter ageism, an experience that can significantly undermine mental well-being. Aging also increases the risk of cognitive impairment and dementia, which are classified as neurocognitive disorders and often co-occur with mental health conditions such as depression or anxiety. It is also important to note that older adults account for more than one fourth of global suicide deaths (WHO, 2023).

Lack of Providers Trained in Working with Older Adults

The growing population of older adults worldwide presents a promising opportunity for mental health professionals given the unique and diverse characteristics of individuals within this age group. The need for mental health professionals who are well-versed in aging-related wellness and mental health care is expected to rise also as younger generations who value mental health support enter later life. However, there is not only a shortage of mental health providers, but also a significant shortage of mental health professionals with clinical experience specific to older adults. As of 2024, over 122 million Americans live in a designated Mental Health Professional Shortage Area, with older adults disproportionately affected (National Center for Health Workforce Analysis, 2024). Some of the possible causes for the general workforce shortage have been identified as including a lack of government funding for mental health services, poor reimbursement rates, low retention rates, increased need for services and limited access to care, and an aging workforce (American Counseling Association, 2023).

Within the current shortage of mental health providers, there is an even greater shortage of mental health providers who specialize in working with older adults. For example, a survey of 4,000 U.S. psychologists revealed that only 1.2% of those surveyed described geropsychology as their specialty area, even though 37.2% reported seeing older adults frequently or very frequently in practice (Moye et al, 2018), which is even a smaller percentage than in previous surveys. A 2002 survey (Qualls et al., 2002) and a 2008 survey (APA, 2010) of APA members both found that only 3% to 4% of survey respondents reported older adults as their primary focus. Today’s workforce is significantly lacking in both size and training to effectively address the current mental health treatment needs of older adults.

Ageism

Ageism is a deeply embedded form of discrimination linked to assumptions about chronological age, and its harmful effects can be seen across the entire lifespan, including older adulthood. It is a widespread bias based on a person’s age, and it can affect individuals at any stage of life, often shaping how care is perceived and given (American Psychological Association, 2025). Some view it as a worldwide crisis that was exacerbated by the COVID-19 pandemic and associated at times with hate speech and human rights violations (Levy et al., 2022). Ageism is especially harmful to older adults because it negatively affects their mental, physical, and social wellbeing by drawing on age-based stereotypes that unfairly depict individuals as less capable or worthy simply because they don’t fit within society’s idealized age norms. Studies underscore how widespread ageism is, with a national survey showing that 93% of U.S. adults between the ages of 50 and 80 have encountered everyday ageism (Allen et al., 2022a), which refers to subtle verbal, nonverbal, or environmental cues that express hostility, devalue older adults, or reinforce limiting stereotypes about them (Allen et al., 2022b). This frequent exposure can lead to internalized negative beliefs, where individuals internalize societal stereotypes about aging into their own self-image, harming both their mental and physical health (Allen et al., 2022; Levy et al., 2022). Ageist beliefs can also impact our longevity, as research has found a 7.5-year difference in lifespan between people who hold positive views on getting older versus those who have negative beliefs about aging (Levy et al., 2022). Overall, ageism leads to numerous harms, disadvantages, and injustices, such as health disparities based on age, and worse overall health outcomes (Mikton et al., 2021).

Ageism, especially internalized beliefs that poor mental health is a normal part of aging, influence how older adults perceive obstacles to accessing mental health care, and these internal and external ageist barriers both contribute to reduced wellbeing (Caskie et al., 2025). Ageist attitudes among mental health providers can contribute to the underdiagnosis and undertreatment of mental health conditions in older adults by reinforcing the mistaken belief that issues like depression are a normal and expected part of aging (APA, 2021). To promote mental health in older adults, mental health providers should actively challenge ageist misconceptions their clients may have internalized and demonstrate both their willingness and competence to offer effective mental health care tailored to older adults (Caskie et al., 2025). Providers should also avoid engaging in Elderspeak, which is an inappropriate and simplified way of speaking that resembles baby talk and is often used with older adults in healthcare settings (Shaw & Gordon, 2021). It is a subtle form of ageism that can perpetuate ageist assumptions that older adults are incompetent or childlike, which can negatively impact both how patients see themselves and how providers treat them.

Case Example

Dr. Johnson, a psychologist who consults at a local long-term care facility, was asked to evaluate Ms. Herrera, an 89-year-old female who had recently withdrawn from group activities. She recently began eating in her room alone instead of in the dining room. Staff noted that she was spending more time alone in her room, sleeping more during the day, and seemed tearful lately. During their first session, Ms. Herrera told Dr. Johnson, “I miss my roommate. Since she passed away, I don’t have the motivation to get out of bed and I don’t want to leave my room. But I do miss playing BINGO with my friends.”

Instead of exploring her grief or assessing for depression, Dr. Johnson responded “It is common as we get older that we want to spend more time alone and take more frequent naps. You’ve lived a long life and feeling sad and lacking energy is just part of getting older.” Ms. Herrera responded, “I want to get back to doing things that I enjoy. I miss my friends.”

Rather than further exploring her motivation to want to re-engage socially or encouraging behavioral activation, Dr. Johnson stated, “It’s understandable that you are likely slowing down and need to rest more.” He neglected to assess for depression, grief, or adjustment disorder and documented “expected age-related decline” in her notes. Over the next few weeks, Ms. Herrera became increasingly withdrawn. Dr. Johnson repeatedly reminded her, “This is typical for someone your age.”

Reflection

In what ways is Dr. Johnson displaying ageist attitudes, beliefs, or behaviors? First, assuming that emotional distress is part of “normal aging” rather than caused by treatable symptoms can stem from ageist beliefs. Second, using stereotypes, such as “slowing down with age”, results in attributing observations to age which have nothing to do with her behavioral change or symptom presentation. Third, minimizing Ms. Herrera’s stated goals of wanting to re-engage with others sends the message that she should just accept her current circumstances, which doesn’t promote improved well-being. Finally, ageism appeared to impact Dr. Johnson’s clinical evaluation and treatment plan by lowering the standard of care resulting from not providing a thorough assessment and/or offering evidence-based interventions.

Mental Health and Aging

Prevalence of Mental Health Conditions Among Older Adults

According to the World Health Organization, approximately 14% of adults aged 70 and over live with a mental health disorder (WHO, 2023). A wide range of mental illnesses can occur, ranging from mild personality changes to severe deterioration of cognitive functioning. Mental health disorders generally become less common in later life (Byers et al., 2010; Reynolds et al., 2015), with a general pattern of decreasing rates of psychiatric disorders with increasing age (Karel et al., 2012; Hybels & Blazer, 2003; Reynolds et al., 2015). Older adults have lower rates of depression, anxiety, schizophrenia, bipolar disorder, and substance use disorders than do younger adults (Byers et al., 2010; Cohen et al., 2018; Depp & Jeste, 2004; Fiske et al., 2009; Gum et al., 2009; Jacobs & Bamonti, 2022; Karel et al.,2012; Reynolds et al., 2015). In a nationally representative U.S. survey, the prevalence of psychiatric disorders in older adults found the prevalence rate for anxiety disorders was 11.4%, 6.8% for past-year mood disorders, 3.8% for any past-year substance use disorder, and 14.5% for personality disorders (Reynolds et al, 2015).

Gender differences in the prevalence of most psychiatric disorders tend to diminish with age, with women generally exhibiting higher rates of mood and anxiety disorders, whereas men show higher rates of substance use disorders and personality disorders (Reynolds, 2015). Over the past decade, rates of alcohol and substance use disorders have increased among older adults, largely as the baby boomer generation has entered later life (Kuerbis, 2020). Certain mental disorders, particularly neurocognitive disorders, hoarding disorder, and sleep disorders, are more common or tend to present with greater severity in older adults compared to younger and middle-aged populations (Jacobs & Bamonti, 2022).

Given that older adults comprise a heterogenous group, distinguishing between normal and pathological aging is a fundamental issue when working with them. Identifying mental health conditions in older adults requires a thorough understanding of research that outlines typical age-related changes across key areas of functioning, such as emotion, personality, and cognition.

Depression

Estimates of depression in older adults vary widely across studies. Abdoli et al. (2022) identified a global prevalence of major depression of 13.3% in later life, with slightly higher rates among older women (11.9%) than older men (9.7%). In contrast, a meta-analysis by Zenebe et al. (2021) found a substantially higher overall prevalence – 31.74% – and noted that depression rates were markedly greater in developing countries (40.78%) than in developed countries (17.05%). Further analysis revealed that associated factors of depression included being female, being older than 75 years, being single, divorced or widowed, being unemployed, retired, no education or low level of education, low level of income, lack of social support, presence of physical illness, physical immobility, and a history of serious life events (Zenebe et al., 2021). Together, these findings highlight both gender differences and significant global variability in depression prevalence among older adults.

Although depression is the most prevalent mental disorder among older adults, it should not be considered a part of normal aging. It is also important to differentiate between normal, short-term emotional responses, such as sadness, and persistent, debilitating depression in older adults, particularly in cases of complicated or pathological bereavement (Patrick et al., 2025). This type of depression is excessive in relation to the loss experienced and may include irrational or self-destructive thoughts and behaviors. Although major depressive disorder (MDD) is less prevalent in older adults (Cherubini et al., 2012), subthreshold depression is more common in this age group and may become more frequent with advancing age. Subthreshold depression refers to the presence of clinically significant depressive symptoms, such as diminished interest or pleasure, feelings of worthlessness, changes in sleep or appetite, low energy, and occasional thoughts of death, that do not meet the full diagnostic criteria for major depressive disorder. Research shows that it is still associated with impaired functioning, increased health-care utilization, and elevated risk for developing major depression. (Adams, 2009; Hybels et al.,, 2001; Rodriguez et al., 2012).

Diagnosing depression in older adults can be difficult, as its somatic symptoms often overlap with or mimic those of medical conditions. Although depression presents many similar core symptoms across different age groups, older adults encounter distinct challenges, particularly related to declining physical health. Research consistently shows that depressive symptoms in older adults are strongly linked to higher levels of daily stress, reduced social interaction, fewer opportunities for pleasurable or meaningful activities, and limited use of effective coping strategies (Chen et al., 2025; Dunkley et al., 2017; Fiske et al., 2009; Glass et al., 2006).

It is essential to establish when depressive symptoms first appeared, as both the presentation of depression and its underlying causes can differ depending on the age at onset (Jacobs & Bamonti, 2022). Early-onset depression (EOD) refers to a chronic or recurring depressive disorder that begins earlier in life, whereas late-onset depression (LOD), accounting for about half of all late-life cases, emerges after the age of 60 to 65 (Aziz & Steffens, 2013). Up to 30% of these patients will have treatment-resistant late-life depression, defined as depression that persists despite two adequate antidepressant trials (Subramanian et al., 2023). Older adults with EOD are more likely to have a family history of depression (Fiske et al., 2009; Gallagher et al., 2010), previous psychiatric hospitalization (Gallagher et al., 2010), greater symptom severity (Xiao et al., 2020), and have more frequent suicidal thoughts (Gallagher et al., 2010), while LOD has been found to be associated with vascular brain changes (Krishnan et al., 1995; Sneed & Culang-Reinlieb, 2011).

Late-life depression often emerges in the context of significant medical burden. Older adults experiencing acute illnesses, progressive chronic conditions, or reductions in mobility and independence (such as difficulty bathing, dressing, or toileting) are at heightened risk for developing depressive symptoms. In some instances, depressive features are directly attributable to a specific neurological or medical illness, for example following a stroke. More broadly, depression commonly co-occurs with chronic diseases that are prevalent in later life, including cardiovascular disease, type II diabetes, cancer, COPD, chronic pain syndromes, and various forms of dementia (Fiske et al., 2009; Matte et al., 2016; Sivertsen et al., 2015; Zis et al., 2017).

When depression goes unrecognized or untreated, older adults may struggle to effectively manage their chronic health conditions. Difficulties with medication adherence, reduced engagement in physical activity, and challenges maintaining healthy nutritional habits can worsen underlying illnesses, which then further compound emotional distress (Fiske et al., 2009; Grenard et al., 2011). This bidirectional relationship contributes to poorer physical functioning and lower overall quality of life among community-dwelling older adults (Ho et al., 2014).

Additionally, comorbidity between depression and anxiety in later life is common and clinically meaningful. Research indicates that more than half of individuals with severe depression (approximately 51%) also meet criteria for an anxiety disorder within the same year, highlighting the importance of thorough assessment and integrated treatment approaches for older adults presenting with mood symptoms (Olfson et al., 2017).

Suicide Risk in Older Adults

Suicide is the 11^th leading cause of death overall in the U.S. (National Institute of Mental Health, 2025). Depression is the most prevalent psychiatric disorder and the leading risk factor associated with suicidal behavior in late life (Beghi et al., 2021; Conwell et al., 2002). Among women, rates peak in midlife (ages 45-64) at 9.8 per 100,000 (National Institute of Mental Health, 2021), whereas men experience the highest rates at age 75 and older, reaching 39.9 per 100,000. The risk is especially elevated for older White men over age 74, with the highest rates observed among those aged 85 and older living in rural areas (Conwell et al., 2011; El Ibrahimi et al., 2021).

Although suicidal ideation tends to decline with age, both suicidal intent and the lethality of means increase (Aziz & Steffens, 2013). Older adults often display fewer or less recognizable warning signs, making detection more difficult. Key risk factors for late-life suicide include major depression, sleep disturbances, chronic pain, frailty, progressive cognitive decline, chronic medical illnesses, and functional disabilities that limit independence. Stressful and destabilizing life events, particularly bereavement, loss of social roles, and increasing isolation, further elevate risk. Importantly, suicide risk tends to increase as the number of co-occurring medical comorbidities rises, reflecting the cumulative burden of illness on physical, emotional, and cognitive functioning (Bernert et al., 2014; Conwell et al., 2011; Draper, 2014; Fiske et al., 2009; Van Orden & Conwell, 2011).

It is important to keep in mind that suicidal thoughts are not a normative part of aging, and their presence in an older adult should always be regarded as clinically significant. Suicidal ideation in later life is uncommon in the absence of underlying, and often treatable, behavioral health conditions, such as major or subthreshold depression, anxiety disorders, substance misuse, cognitive impairment, or significant psychosocial stressors (Conwell & Thompson, 2008; Van Orden et al., 2015). When suicidal thoughts occur, they should be treated as a critical warning sign that warrants a thorough mental health risk assessment. Such an evaluation helps identify the medical, psychological, social, and environmental factors contributing to distress and guides the development of appropriate interventions. Timely recognition and treatment of these underlying issues can significantly reduce suicide risk and enhance overall quality of life for older adults.

Anxiety

Anxiety disorders are the most common form of mental health condition in the United States, with a lifetime prevalence of 28.8% (Kessler et al., 2005) and 10.4% globally (Baxter et al., 2013). Anxiety is common in late-life depression, both as a symptom and as a comorbid disorder (Lenze et al., 2000). Anxiety disorders are the most prevalent psychological condition among older adults (Gum et al., 2009). While prevalence rates vary, epidemiological studies estimate that around 10% of older adults experience an anxiety disorder at any given time (Ayers et al., 2007).

Lifespan studies of anxiety disorders indicate that different types of anxiety tend to be more prevalent at specific stages of life (Jacobs & Bamonti, 2023). Although many anxiety disorders begin earlier in life, a substantial number of generalized anxiety disorder (GAD) cases first emerge in later life. Research suggests that roughly one-third to one-half of older adults with GAD report onset after midlife (often after age 50) and that agoraphobia, while typically of earlier onset, can also arise de novo in older adults, particularly women and those with significant medical illness or functional decline (Bassil, 2011; Lenze & Wetherell, 2011; Beekman et al.,2015). Around half of older adults with generalized anxiety disorder (GAD) and agoraphobia develop these conditions later in life (Andreescu & Varon, 2015; LeRoux et al., 2005). Although late-life generalized anxiety disorder (GAD) presents with many of the same core symptoms observed in younger adults, the content of worry often differs markedly. Older adults tend to focus their worries on health problems, physical limitations, medical procedures, and potential loss of independence, whereas younger and middle-aged adults are more likely to experience worries centered on work, finances, and career-related stressors (Ribeiro et al., 2015; Wolitzky-Taylor et al., 2010).

Mirroring findings in early-onset depression, early-onset GAD (with onset prior to age 60-65) is generally linked to a more complex clinical profile. Older adults in this group tend to exhibit higher rates of co-occurring psychiatric conditions and more intense anxiety symptoms compared to those whose GAD first emerges in later life. (Le Roux et al., 2005). This underscores the importance of asking detailed questions during the clinical interview about how long anxiety symptoms have been present and how often they occur.

Diagnosing anxiety in older adults can be challenging due to its frequent overlap with medical conditions and the tendency of older individuals to attribute anxiety symptoms to physical health issues (Wolitzky-Taylor et al., 2010). Disorders such as Parkinson’s disease, chronic obstructive pulmonary disease (COPD), and cardiovascular disease often co-occur with anxiety, and older adults with chronic illnesses may be at greater risk for developing anxiety symptoms compared to their peers without such conditions (Wolitzky-Taylor et al., 2010). Medical issues that affect the heart, lungs, or balance system are common in late life and share a bidirectional relationship with anxiety (Wolitzky-Taylor et al., 2010). The co-occurrence of anxiety and physical illness has been associated with poorer treatment outcomes (Wolitzky-Taylor et al., 2010). As various medical conditions can generate physical sensations similar to anxiety, and many medications commonly used by older adults can produce anxiety-like side effects, it is crucial to determine when symptoms first appeared, and carefully review the individual’s medical history. Establishing this timeline helps distinguish true anxiety disorders from symptoms driven by underlying health problems or treatment effects in late life (Beekman et al., 2015; Bryant et al., 2013; Flint & Rifat, 2002).

Case Example

Mr. Miller is a 74 y/o male who was recently hospitalized for pneumonia. Since being admitted to a short-term rehab facility, staff have noticed he has been using his call light “every five minutes” and asking for reassurance about his oxygen levels. He has been sleeping in his recliner rather than getting into his bed. He often sits upright in his recliner, gripping the armrests, breathing quickly even when his oxygen saturation is normal. He has recently been refusing to go to physical therapy for fear that he won’t be able to catch his breath and fears he will fall. Because of these changes, Mr. Miller has been referred for psychological evaluation.

As part of the evaluation process, the mental health provider reviewed Mr. Miller’s medical records and determined that besides recently having pneumonia, he also has a long-standing history of COPD. He also had an incident of falling at home prior to his recent hospitalization. The provider also consulted with staff to determine the timing of his behavioral changes and emotional symptoms. The provider understood that symptoms of COPD often mimic anxiety and that people with COPD have much higher rates of anxiety than the general population.

During the clinical interview, the provider screened for anxiety using the Generalized Anxiety Disorder-7 (GAD-7) (Spitzer et al., 2006), in addition to asking questions during the clinical interview about types of symptoms, frequency and timing of symptoms, and possible triggers to anxiety. Through the evaluation process, it was determined that although Mr. Miller does exhibit physical signs of anxiety at times of COPD exacerbations and since recovering from pneumonia, he has a long-standing history of generalized anxiety symptoms and admits to chronic worrying. He reported having catastrophic thoughts related to standing up, indicating that “If I try to walk I will fall, break a hip, and end up back in the hospital.” Mr. Miller’s mental status exam revealed that his cognitive impairment was within normal limits. His fear of falling is reinforced by his recent experience of falling at home in his bathroom where he reportedly remained on the floor unable to get up for three days until a neighbor found him.

It was determined that Mr. Miller would benefit from cognitive-behavioral therapy focused on anxiety management, which he was agreeable to. He was also agreeable to having physical therapy (PT) staff join sessions to collaboratively work on managing anxiety while PT staff worked with him on standing up and walking. Within a few sessions, Mr. Miller reported decreased anticipatory anxiety and was engaging in PT and making notable progress. As his progress in PT continued, he continued to report decreased anxiety and reported no longer catastrophizing about the possibility of falling. He eventually regained physical functioning and was able to return home.

Reflection

If the mental health provider would have initially assumed that anxiety symptoms were solely linked to COPD or recent pneumonia, there would have been a missed opportunity to focus on identifying specific triggers and fears related to falling, which likely would have had a different outcome for Mr. Miller (e.g., he would likely have continued to decline participating in PT and may not have been able to return home as soon, or at all).

Substance Use Disorders

Substance misuse, particularly involving alcohol, prescription benzodiazepines, and opioids, is an increasingly significant health concern among Americans aged 60 and older (Paun & Loukissa, 2023). While substance use disorders were historically considered less common in older adults, recent data suggest that prevalence rates are rising due to factors such as the aging of the “Baby Boomer” generation (those born circa 1946-1964), who have higher rates of substance use when younger compared to previous generations (Yarnell et al., 2020). Other reasons explaining the higher prevalence include cultural and attitudinal changes associated with substance use and higher lifetime levels of exposure (Akwe et al., 2023; Yarnell et al., 2020).

Older adults are using illicit drugs and meeting the criteria for substance use disorders (SUDs) at higher rates than previous generations, leading to significant adverse effects on their medical and mental health conditions (Yarnell et al., 2020). However, Substance use disorder (SUD) in this population is often underestimated, resulting in missed chances for proper diagnosis and treatment. The risk of developing SUD is heightened by chronic medical conditions, mental health challenges, and psychosocial stressors common in later life (Paun & Loukissa, 2023). Additionally, some racial and ethnic minority groups face greater vulnerability to SUD due to healthcare disparities and limited access to resources (Paun, & Loukissa, 2023).

Alcohol is the most used substance among older adults, with approximately 65% of individuals aged 65 and older reporting high-risk drinking – defined as exceeding daily recommended limits at least once a week over the past year (NIDA, 2020). Problematic alcohol use raises the risk of injuries, depression, sleep problems, cognitive impairment, and dangerous interactions with medications (Barry & Blow, 2016; Blow & Barry, 2012). Both lifetime and current cocaine use are more common among Baby Boomers compared to older generations (Akwe et al., 2023). Cannabis use among older adults has been increasing, driven by its decriminalization, legalization, and growing social acceptance (Kuerbis, 2020). The prevalence of past-month cannabis use among older adults increased significantly from 4.8% in 2021 to 7.0% in 2023 (Han et al., 2025). Research suggests that older adults use cannabis to help manage pain and symptoms associated with chronic conditions; however, more studies are needed to fully understand its therapeutic effects and potential side effects (Kuerbis, 2020; Manning & Bouchard, 2021).

Personality Disorders

Personality disorders are understood as enduring and extreme patterns of personality traits that impair daily functioning, and they are expected to be present in a subset of older adults (Lenzenweger et al., 2007). Population-based studies over the past decade have shown that although the prevalence of personality disorders (PDs) decreases with age, they remain relatively common compared to other mental disorders (Schuster et al., 2013). However, studies have shown a higher prevalence of PDs in older adults residing in nursing homes (57.8%) in comparison to community-dwelling older adults (10.6-14.5%) (Penders et al., 2020). A lower prevalence of antisocial personality disorder (ASPD) among older adults compared to younger adults is well-established in the literature (Holzer & Vaughn, 2017). The prevalence of ASPD rises during early adulthood, reaching a peak of 3.91% among younger adults, and then declines to 0.78% in individuals aged 65 and older (Holzer et al., 2020).

Older adults with a personality disorder commonly experience chronic health conditions, mental disorders, and disabilities (Schuster et al., 2013), and face a higher risk of stroke, heart disease, and increased mortality (Dixon-Gordon et al, 2015). These disorders are also linked to elevated risks of obesity, being underweight, smoking, alcohol use disorder, diabetes, arthritis, and gastrointestinal conditions (Dixon-Gordon et al, 2015). Personality disorders in late life are also linked to lower perceived quality of life, suicidal thoughts and suicide risk, and poorer mental health outcomes (Mattar & Khan, 2017; Penders et al., 2020; Szanto et al., 2018). Older adults with ASPD are more likely to be diagnosed with substance use disorder, major depression, mania, and generalized anxiety disorder (Holzer et al., 2020). ASPD is also specifically linked to a higher risk of accidental injuries and increased rates of infections like hepatitis C and HIV (Black, 2015).

Diagnosing personality disorders in older adults presents several unique challenges. One major difficulty is determining whether the observed personality traits and functional impairments have been present since adolescence or early adulthood (Brudey, 2021). As suggested by Brudey (2021), many diagnostic criteria for personality disorders may not be appropriate for older adults. For example, older individuals with ASPD may be incapable of engaging in behaviors such as fighting or assault due to frailty or physical status. Additionally, some criteria refer to work-related impairments, such as persistent failure to maintain employment in antisocial personality disorder, or excessive dedication to work in obsessive-compulsive personality disorder, which may not apply to older adults who are retired. Given that various medical conditions can lead to changes in personality, it is particularly important to gather a detailed history of events such as falls, concussions, brain injury, motor vehicle accidents, strokes, severe illnesses that caused delirium, or conditions requiring intensive care unit treatment, and confirm that maladaptive personality traits were present and causing clinically significant functional impairment prior to the onset of the medical event (Brudey, 2021). Although few instruments are available that were developed to assess personality in older adults (Penders et al., 2020), the Gerontological Personality disorders Scale (GPS) is a 16-item screener that was designed to detect personality disorders among older adults (van Alphen et al., 2006).

Neurocognitive Disorders

The Aging Brain

To better understand neurocognitive disorders, a fundamental understanding of the aging brain is necessary. Over the course of normal aging, the brain undergoes a wide array of structural (e.g., brain volume loss, grey and white matter alterations), biochemical and metabolic (e.g., declines in key neurotransmitter systems), and cellular/molecular (e.g., mitochondrial dysfunction, impaired proteostasis, calcium dysregulation) changes (Lee & Kim, 2022). Neuroimaging studies indicate that changes in brain structure occur much earlier than in late life, and the notion of a static “mature” brain that remains unchanged until old age is inaccurate. Previous longitudinal studies have shown that brain atrophy begins in the 40s and that the annual volume change rate increases with age (Resnick et al., 2003). A more recent large meta-analysis of longitudinal MRI studies found that starting around age 35, brain volume declines at a rate of approximately 0.2% per year. This rate gradually increases, reaching about 0.5% annually by age 60. After 60 years of age, individuals typically experience a consistent brain volume loss exceeding 0.5% per year (Hedman et al., 2012).

As we age, the brain experiences several important structural changes, which mainly include loss of gray and white matter volume, enlargement of the ventricles, and widening of the sulci. The rate of temporal lobe atrophy begins to accelerate around age 70, following earlier increases in atrophy rates in the hippocampus and amygdala (Fujita et al., 2023). Although these changes are typical of normal brain aging, neurodegenerative diseases like Alzheimer’s disease (AD) and related dementias significantly accelerate these processes, leading to a marked deviation from the normal aging pattern seen in cross-sectional studies (Blinkouskaya & Weickenmeier, 2021).

Certain brain regions, including subcortical white matter and basal ganglia, as well as regions supplied by terminal arterioles (small blood vessels that supply blood to specific, isolated regions of tissue without significant collateral circulation), appear more vulnerable to age-related structural change (atrophy, demyelination, microvascular injury) (Pansieri et al., 2024; Rudolph et al., 2024; Zimmerman et al., 2021). These regions may suffer earlier functional impairment if blood supply is chronically reduced. Simultaneously, brain aging is marked by notable glial cell changes, such as increased astrocyte size and number, alongside structural alterations like ventricular enlargement and progressive myelin thinning (Esiri, 2007; Garcia-Dominguez, 2025; La Sala & Farini, 2025; McCray et al., 2024).

From a neurochemical standpoint, key neurotransmitter systems, including the dopaminergic pathways in the substantial nigra and basal ganglia, show measurable decline with increasing age (Perez-Lloret & Barrantes, 2016; Salvatore, 2024; Zaman et al., 2008). This likely contributes to reductions in motor function, slower cognitive processing speed, and heightened apathy in older adults (Clerx et al., 2021; Ismail, & McGowan, 2023).

Cellular senescence, the biological process in which cells permanently stop dividing in response to stress, damage, or aging, is a hallmark of biological aging and plays a significant role in the onset and progression of neurodegenerative diseases. The accumulation of senescent, or aging, cells in the brain contributes to aging-related cognitive decline via mechanisms like neuroinflammation, impaired neurogenesis, synaptic dysfunction, and blood-brain-barrier disruption (Areez Shafqat et al., 2023). Contrary to earlier beliefs that normal aging involves widespread neuronal death, newer research indicates that neuron loss in most brain regions is relatively limited and instead aging is marked by more subtle changes, including dendritic shrinkage, synaptic loss, and reduced cell body size (Ibanez et al., 2024; Lee & Kim, 2022; Walker et al., 2024). Biochemical and metabolic changes contribute to age-related cognitive decline and increase the brain’s susceptibility to neurodegeneration, particularly Alzheimer’s and Parkinson’s diseases (Lee & Kim, 2022). A brief summary of the main biochemical and metabolic alterations are found in Table 1, but readers are encouraged to refer to Lee and Kim (2022) for further details.

Table 1. Biochemical and Metabolic Changes in the Aging Brain

 

Category	Description	Implications
Neurotransmitter Decline	Decreased levels of dopamine, serotonin, norepinephrine, and acetylcholine	Impaired cognition, mood regulation, memory, and motor function
Mitochondrial Dysfunction	Reduced adenosine triphosphate (ATP) production and increased ROS (reactive oxygen species) generation due to aging mitochondria	Energy deficits and oxidative damage to neurons
Glucose Hypometabolism	Decline in glucose uptake and utilization, especially in energy-demanding regions like the hippocampus	Cognitive decline and increased vulnerability to neurodegeneration
Oxidative Stress	Increased ROS with insufficient antioxidant response, leading to damage of proteins, lipids, and DNA	Promotes neuronal aging and contributes to diseases like Alzheimer’s
Calcium Dysregulation	Impaired calcium buffering and signaling in neurons	Triggers neurotoxicity, synaptic dysfunction, and cell death
Impaired Proteostasis	Decreased function of protein degradation systems (e.g., proteasome, autophagy)	Accumulation of damaged or misfolded proteins, common in neurodegenerative diseases
Lipid Metabolism Changes	Altered lipid composition of neuronal membranes affects their fluidity and function	Disrupts synaptic signaling and may promote inflammation

 

In summary, brain aging begins earlier than many people realize; structural and volumetric changes start in young adulthood (after the mid-30s) and progress across the lifespan. These changes occur gradually through midlife and accelerate in later adulthood. Instead of widespread neuron loss in healthy aging, the brain undergoes more subtle alterations, such as synaptic reduction, dendritic shrinkage, vascular changes, and shifts in glial functioning. Some regions are more vulnerable than others, especially those with weaker or more fragile blood supply. Declines in neurotransmitter systems, such as dopamine, along with vascular and white-matter injury, further contribute to the cognitive and functional changes observed in older adulthood.

Cerebrovascular Integrity

The vascular system plays a central role in brain aging and is one of the most powerful predictors of brain health. Growing evidence suggests that cardiovascular disease and its associated risk factors increase the risk of developing both vascular cognitive impairment and Alzheimer’s disease (AD) (Attems & Jellinger, 2014; Helzner et al., 2009; Kloppenborg et al., 2008; Rundek et al., 2022). Hypertension is prevalent among adults and older individuals and serves as a major risk factor for vascular cognitive impairment and dementia in later life (Santisteban et al.,, 2023). Other common vascular risk factors that can accelerate brain aging via vascular injury include diabetes (Kloppenborg et al., 2008), smoking (Rusanen et al., 2011), and high cholesterol (Helzner et al., 2009). In midlife, hypertension accounts for the highest population attributable risk for dementia, contributing to as much as 30% of late-life dementia cases. In contrast, diabetes emerges as the most significant risk factor for dementia in older age (Kloppenborg et al., 2008). Elevated total cholesterol and LDL-C levels prior to diagnosis, along with a history of diabetes, were linked to more rapid cognitive decline in individuals with newly diagnosed Alzheimer’s disease, reinforcing the contribution of vascular risk factors to the progression of AD (Helzner et al., 2009).

Smoking is increasingly recognized as a risk factor for dementia (Rusanen et al., 2011; Zhong et al., 2015). Research suggests that there can be long-term consequences to smoking, as heavy smoking in midlife has been associated with a greater than 100% increase in risk of dementia, AD, and Vascular dementia even several decades later (Rusanen et al., 2011). Compared with men who have never smoked, middle-aged men who smoke are more likely to experience a faster 10-year decline in global cognition and executive functioning, while intermittent smokers and recent ex-smokers also demonstrate greater cognitive decline (Sabia et al., 2012). Overall, hypertension, high cholesterol, diabetes, and smoking at midlife are each associated with a 20% to 40% increased risk of dementia (Rundek et al., 2022).

Multiple cerebrovascular mechanisms contribute to cognitive impairment, including cerebral small vessel disease, large-artery atherosclerosis, intracerebral hemorrhages, and other stroke etiologies (Rundek et al., 2022). As the brain ages, multiple vascular‐related changes also occur. For example, cerebral blood flow gradually declines with age, vessels thicken, capillaries become less dense, and nutrient/oxygen delivery becomes less efficient (Chen et al.,2011; Scioli et al., 2014; Xu et al., 2017). These changes mean that vascular risk factors can accelerate brain damage (e.g., ischemia, micro‐infarcts) rather than being simply incidental to aging (Brown & Thore, 2011; Brundel et al., 2012; Yang et al., 2017). Age, along with genetic, environmental, and lifestyle factors, promotes the development of vascular risk factors and subclinical arterial and brain pathology, ultimately leading to cerebral blood flow disturbances and network dysfunction (Chen et al., 2024; Wrigglesworth et al., 2021).

Normal Cognitive Aging

Differentiating normal aging from pathological aging is a fundamental aspect of geropsychological assessment (Mast et al., 2022). Familiarity with research describing typical patterns of aging across key domains, such as cognition, emotion, and personality, is essential for clinical practice in order to avoid ageist assumptions or mistaken beliefs. Keep in mind that the heterogeniety among older adults in functioning is important as well when considering what is “normal” aging, as the wide range of functional abilities among older adults makes the concept of normal cognitive aging somewhat ambiguous. For example, while approximately 30%-40% of adults aged 85 and older show clinical symptoms consistent with dementia, these cognitive impairments are not considered a normal or inevitable part of aging (Hebert et al., 2013; Plassman et al., 2007). Dementia reflects underlying disease processes, such as Alzheimer’s disease, vascular pathology, Lewy body disease, or other neurodegenerative conditions, rather than typical age-related cognitive change. Even in adults in the oldest cohort, most cognitive abilities decline only modestly with age, and dementia represents a pathological deviation from what is expected in healthy aging. The distinction between normal and pathological cognitive aging is more accurately understood in terms of primary versus secondary aging – that is, whether the observed changes result from the natural aging process itself (primary aging) or from medical conditions or other factors that often occur alongside aging (secondary aging) (Mast et al., 2022).

Aging is not a uniform experience, as it is shaped by cultural values, beliefs, socioeconomic factors, and historical context. Understanding these multicultural influences helps mental health professionals distinguish between normal aging variations and pathological changes across diverse populations. For example, Western cultures often emphasize independence and productivity in relation to cognitive health, whereas some collectivist cultures may value wisdom and interdependence as signs of normal aging. It is also important to keep in mind that cognitive performance is influenced by the level of education, literacy, and language background, which can differ across cultural and socioeconomic groups (Barba et al., 2021; de Resende et al., 2022; Sharp & Gatz, 2011; Wright et al., 2019).

Delirium

Delirium, characterized by a sudden decline in cognition and attention, is a prevalent neuropsychiatric condition among older adults, occurring in up to 42% of hospitalized patients (Siddiqi et al., 2006). It is the most frequently occurring acute disorder of cognitive functioning in older patients (Iglseder et al., 2022) and is associated with increased mortality, increased length of hospital stay, and long-term functional and cognitive impairment (Morandi et al., 2019; Siddiqi et al., 2006). The causes are diverse and multifactorial, often linked to acute medical conditions, adverse medication effects, or other medical complications, and any associated cognitive impairments often improve once the underlying cause is treated. Advanced age, the presence of multiple comorbid conditions, recent surgical procedures, and the use of multiple medications are all independent risk factors for developing delirium (Jaqua et al.,, 2023).

According to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), delirium is defined as a disturbance in attention and awareness that develops over a short period of time, and which also includes a disturbance in cognition, such as memory, disorientation, language, visuospatial, or perceptual impairment (American Psychiatric Association, 2022). One of the key factors is that the disturbance can’t be explained by a medical condition (such as a urinary tract infection) or by a pre-existing neurocognitive disorder. Delirium is diagnosed when there is a known physiological cause for the acute cognitive disturbance from either from history, physical examination, or laboratory findings. The source could be a medical condition, substance intoxication or withdrawal, exposure to a toxin, or due to multiple etiologies. It is specified as Acute if the disturbance lasts only a few hours or days, whereas it is considered Persistent if lasts weeks to months. The DSM-5-TR diagnostic criteria for Delirium are summarized in Table 2.

Table 2: DSM-5-TR Diagnostic Criteria for Delirium with Description of Criterion Symptoms

 

Criterion	Description
A. Disturbance in attention and awareness accompanied by reduced awareness of the environment	Reduced ability to sustain attention, stay focused, or direct attention, with accompanying decreased orientation to their surroundings
B. The disturbance develops over a short period of time	The disturbance develops over a short period (usually hours to a few days) and represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of the day
C. Additional disturbance in cognition	Includes memory deficit, disorientation, language disturbance, visuospatial ability impairment, or perceptual distortion
D. Not better explained by another preexisting or evolving neurocognitive disorder	The disturbances are not better accounted for by another neurocognitive disorder and do not occur in the context of a severely reduced level of arousal (e.g., coma)
E. Evidence of a physiological cause	There is evidence (from history, physical examination, or laboratory findings) that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (e.g., from drug of abuse or medication), exposure to a toxin, or multiple etiologies

 

When working with older adults who present with cognitive concerns, it is important to first rule out whether a delirium could be a contributing factor. This can be done by gathering information about the timing of the symptoms. For example, is the timing associated with the start of a new medication or during a time when they were diagnosed with an acute infection such as a urinary tract infection (UTI)? Although cognitive symptoms related to delirium can linger for months, they generally dissipate once the contributing factor is effectively treated. The onset of symptoms in delirium are usually acute and abrupt (hours to days) compared to gradual (months to years) as with other cognitive conditions such as dementia. In a delirium, the course of symptoms often waxes and wanes throughout the course of a day, whereas symptoms associated with other cognitive conditions often have a steadier progressive decline (except in cases of vascular dementia where there can be a stepwise progression of symptoms).

Mild Cognitive Impairment

Mild Cognitive Impairment (MCI) is a broad clinical syndrome characterized by subtle memory difficulties and other minor cognitive changes, often representing a transitional stage between normal aging and dementia (Morris, 2005). MCI describes a level of cognitive decline that does not significantly interfere with daily functioning and does not meet the full diagnostic criteria for dementia (Gerstenecker & Mast, 2015). The overall prevalence of MCI has been found to be 15.56% worldwide in community-dwelling adults aged 50 years and older and increases with age and decreases with education level (Bai et al., 2022).

Mild Neurocognitive Disorder is the diagnosis given when there is evidence of modest cognitive decline in one or more cognitive domains, such as learning and memory, complex attention, executive function, language, visuospatial abilities, social cognition that is noticeable to the individual or others and objectively demonstrated on cognitive testing, but does not significantly interfere with independence in daily activities (American Psychiatric Association, 2022). The individual may need to work harder, rely on strategies, or take additional time to manage everyday tasks. The cognitive difficulties are not limited to periods when the person may be experiencing delirium. One of the key differences between MCI and dementia (or Mild Neurocognitive Disorder and Major Neurocognitive Disorder) is that the cognitive deficits in MCI do not interfere with independence in everyday activities (e.g., such as medication management or taking care of one’s daily needs). Mild Neurocognitive Disorder can also be specified to indicate the medical or substance etiology (e.g., due to Alzheimer’s disease, Vascular disease, Parkinson’s disease, etc.). Table 3 summarizes the DSM-5-TR diagnostic criteria for Mild Neurocognitive Disorder.

Table 3: DSM-5-TR Diagnostic Criteria for Mild Neurocognitive Disorder (American Psychiatric Association, 2022):

 

Criterion	Description
A. Evidence of modest cognitive decline	There is modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: Concern of the individual, a knowledgeable informant, or the clinician; and Modest impairment documented by standardized neuropsychological testing or another quantified clinical assessment.
B. Cognitive deficits do not interfere with independence in everyday activities	Cognitive deficits do not interfere with complex instrumental activities of daily living, such as paying bills or medication management; but greater effort or compensatory strategies may be required.
C. Cognitive deficits do not occur exclusively in the context of delirium	The cognitive decline is not just an acute change in mental status that is attributable to a known medical condition or substance.
D. Cognitive deficits are not better explained by another mental health condition	The deficits are not primarily due to another mental disorder, such as Major Depressive Disorder or Schizophrenia.

 

Dementia

Dementia, also known as Major Neurocognitive Disorder, is characterized by a significant decline in one or more cognitive domains that significantly interferes with daily functioning. It impacts over 6 million Americans (Rajan et al., 2021), leads to more than 100,000 deaths annually (Kochanek et al., 2017), and carries an estimated economic cost of $600 billion each year in the United States (Nandi et al., 2022). The prevalence of dementia increases with age, with an estimated 5% prevalence of dementia among individuals between the ages of 71 and 79, and over 37% for those 90 and over (Plassman et al., 2007). Dementia symptoms are caused by a range of underlying pathologies, including those associated with Alzheimer’s disease, Lewy bodies, and vascular cognitive impairment (Chang & Chang, 2022; Jack et al., 2018, 2019; McKeith et al., 2017). The global burden of dementia among older adults has grown substantially over the past three decades, mainly because populations are aging, but improvements in age‐specific rates have been modest (Xiaopeng et al., 2025). It is estimated that by 2050, there will be 152 million people living with dementia (GBD 2019 Dementia Forecasting Collaborators, 2022). Women are disproportionately impacted by dementia, both as those affected and as caregivers. They experience higher rates of dementia-related mortality and disability-adjusted life years, while also providing roughly 70% of the caregiving hours for individuals living with the condition (WHO, 2023).

Symptoms of dementia vary depending on the underlying cause and the areas of the brain impacted, but they generally involve a decline in cognitive, behavioral, and functional abilities that significantly interfere with daily life. Cognitive symptoms may include memory loss, such as forgetting recently learned information, impaired reasoning, disorientation, difficulty with language, attention and concentration difficulty, and poor judgment and/or lack of insight. Depending on the type of dementia, symptoms may show a gradual onset (as with Alzheimer’s Dementia) or a sudden and abrupt onset (as with Vascular Dementia following a stroke).

Approximately 90% of individuals with dementia experience additional psychological or behavioral symptoms, which significantly contribute to functional decline and heightened caregiver burden (Cerejeira et al., 2012; Okabe et al., 2020; Schwertner et al., 2022). Behavioral and Psychological Symptoms of Dementia (BPSD) may include emotional symptoms, changes in personality, agitation, and even psychotic symptoms such as hallucinations or delusions. Functionally, dementia will significantly impact the person’s ability to perform daily activities of living, such as cooking, medication management, and/or driving. It can also impact motor symptoms resulting in unsteady gait and increased falls. Table 4 summarizes common symptoms of dementia with examples.

Table 4. Common Symptoms of Dementia with Behavioral Examples

 

Category	Common Symptoms	Description/Examples
Cognitive Symptoms	Memory loss	Forgetting recent events, names, or conversations; repeating questions
	Impaired reasoning and problem-solving	Difficulty making decisions, managing finances, or planning activities
	Disorientation	Confusion about time, date, or familiar places
	Language difficulties	Trouble finding words, following conversations, or expressing thoughts
	Attention and concentration problems	Easily distracted, difficulty focusing on tasks or conversations
	Poor judgment and insight	Engaging in unsafe behaviors or failing to recognize one’s limitations
Behavioral & Psychological Symptoms	Personality and mood changes	Increased irritability, anxiety, apathy, or depression
	Agitation or aggression	Restlessness, frustration, or emotional outbursts
	Hallucinations or delusions	Seeing or believing things that are not real (more common in Lewy body dementia)
Functional Symptoms	Difficulty with daily activities	Trouble managing daily tasks like cooking, dressing, or using appliances
	Loss of coordination or motor skills	Unsteady gait, difficulty using familiar objects, or frequent falls

 

Diagnosing Major Neurocognitive Disorder (dementia) includes observing evidence of significant decline in one or more areas of cognition, including complex attention, executive functioning, learning and memory, language, perceptual-motor or visual constructional ability, and/or social cognition compared to the person’s previous level of functioning. The deficits significantly impact the ability to carry out activities of daily living and are not better accounted for by delirium or other mental health conditions, and this is what distinguishes it from Mild Neurocognitive Disorder. The known medical or substance etiology can also be specified, (such as Alzheimer’s disease, Frontotemporal degeneration, Lew Body disease, etc.). Refer to Table 5 for a summary of the DSM-5-TR diagnostic criteria for Major Neurocognitive Disorder (American Psychiatric Association, 2022).

Table 5. DSM-5-TR Diagnostic Criteria for Major Neurocognitive Disorder

 

Criterion	Description
A. Evidence of significant cognitive decline	There is evidence of significant decline from a previous level of performance in one or more cognitive domains (complex attention, executive functioning, learning and memory, language, perceptual–motor function, or social cognition). Evidence must come from: Concern of the individual, a knowledgeable informant, or the clinician; and Substantial impairment on standardized neuropsychological testing or another quantified clinical assessment.
B. Cognitive deficits interfere with independence in everyday activities	The cognitive deficits interfere with independence in everyday activities (e.g., needing help with complex instrumental activities such as paying bills, managing medications, shopping).
C. Cognitive deficits do not occur exclusively in the context of delirium	The cognitive decline is not better explained by delirium or other acute confusional state.
D. Cognitive deficits are not better explained by another mental health condition	The deficits are not primarily due to another mental disorder, such as Major Depressive Disorder or Schizophrenia.

 

Alzheimer’s Dementia

Dementia related to Alzheimer’s Disease (AD) is the most prevalent and common form of dementia. Currently, an estimated 7.2 million Americans aged 65 and older are living with Alzheimer’s dementia. Without significant medical advances in prevention or treatment, this number is projected to rise to approximately 13.8 million by 2060 (Alzheimer’s Association, 2025). The buildup of beta-amyloid protein outside neurons and twisted tau protein fibers within neurons are key hallmarks of the disease. These changes are accompanied by neuronal death, brain tissue damage, inflammation, and brain atrophy (Alzheimer’s Association, 2025). In Alzheimer’s disease, the earliest neuronal damage occurs in brain regions involved in memory, language, and thinking, which explains why initial symptoms typically include difficulties in these areas. The underlying brain changes are believed to begin 20 years or more before noticeable symptoms emerge (Bateman et al., 2012; Caselli et al., 2020; Sperling et al., 2014).

Symptoms of AD typically begin with having difficulty recalling newly learned information. Symptoms tend to have a gradual onset and show progressive worsening over time. This may take the form of asking the same questions repeatedly, forgetting recent conversations, misplacing important items, and/or forgetting recent events. Difficulty with planning and problem-solving may also be present, which might include difficulty making decisions, difficulty balancing a checkbook, or difficulty following multi-tasking. Even familiar or routine tasks may be difficult, such as getting lost while driving to a familiar store. Individuals may also display impairment in language, such as difficulty with word-finding or calling something by the wrong name. Emotionally, mood and personality changes are common in AD (Ahmadi et al., 2025; Hippius & Neundorfer, 2003; Terracciano & Sutin, 2019), such as becoming suspicious, depressed, fearful, anxious, irritable, or withdrawn. As the disease progresses individuals may not recognize familiar faces or names of family members. Often in the later stages, severe memory loss is observed and there may be limited or minimal communication. Often individuals with late-stage dementia will require complete dependence with all activities of daily living, such as dressing, bathing, toileting, and eating. Loss of mobility can also occur, which can lead to an inability to walk or sit up independently. Behavioral and psychological symptoms that may be observed include apathy and withdrawal, agitation or restlessness, hallucinations or delusions, and disruption in sleep-wake cycle. Refer to Table 6 for more information about the stages of AD.

Table 6. Progression of Alzheimer’s Disease: Symptoms by Stage

 

Stage	Description	Common Symptoms
1. Preclinical Alzheimer’s Disease	Brain changes (amyloid and tau buildup, neuronal injury) occur years (often decades) before symptoms appear	No outward symptoms; subtle changes in brain metabolism or structure detectable with biomarkers or imaging
2. Mild Cognitive Impairment (MCI) due to AD	Early measurable cognitive decline greater than expected for age, but daily functioning mostly intact	Mild forgetfulness (especially recent events) Word-finding difficulty Trouble with complex tasks or decision-making
3. Mild Alzheimer’s Disease	Noticeable impairment begins to affect daily life	Increasing memory loss Repetition of questions/statements Difficulty managing money, planning, or organizing Getting lost in familiar places Personality or mood changes (e.g., irritability, anxiety)
4. Moderate Alzheimer’s Disease	Symptoms intensify and independence declines	Significant memory gaps and confusion Difficulty recognizing friends/family Language problems (e.g., short sentences, repetition) Sleep disturbances Wandering or agitation Poor judgment and impulse control
5. Severe Alzheimer’s Disease	Major loss of cognitive and physical abilities; full-time care required.	Loss of ability to communicate coherently Dependence with all activities of daily living (ADLs) Incontinence Difficulty swallowing and walking Weight loss and vulnerability to infections

 

Vascular Dementia

Vascular dementia (VaD) (also referred to as Vascular Neurocognitive Disorder in the DSM-5-TR) describes a form of dementia caused by a vascular etiology such as cerebrovascular disease. Such vascular etiology typically involves damage to brain tissue resulting from ischemia, infarction (stroke), or hemorrhage (Chang & Chang, 2022). VaD is the second most common cause of dementia and accounts for approximately 20% of all dementia cases, with its prevalence closely mirroring patterns of stroke risk (Bir et al., 2021). In Asia and several developing countries, the estimated prevalence of vascular dementia is believed to approach 30% (Chan et al., 2013; Kalaria et al., 2008). The primary risk factors for vascular cognitive impairment and dementia are cardiovascular in nature, including hypertension, hyperlipidemia, type 2 diabetes mellitus, smoking, and atrial fibrillation (Chang & Chui, 2022).

Symptoms of VaD have a heterogenous presentation, depending on the area of the brain that is impacted. The classical course of symptoms is often stepwise, with sudden declines after new vascular events. Executive dysfunction and psychomotor slowing are hallmark features of vascular cognitive impairment, reflecting disruption of frontal-subcortical circuits. In subcortical ischemic vascular dementia, the progression is usually gradual, characterized by worsening executive dysfunction and a decline in processing speed or complex attention (Chang & Chang, 2022). In the early stages, processing speed and/or executive functioning difficulties may be more common than memory deficits. Individuals with a history of stroke may exhibit prominent language or memory impairments, depending on the site of the cerebrovascular lesion. Multi-infarct dementia involves multiple large cortical infarcts contributing to vascular cognitive impairment and dementia, with cognitive assessment often revealing cortical features such as apraxia, aphasia, visual field deficits, or neglect (Chang & Chang, 2022). Compared to individuals with AD, individuals with VaD have been shown to exhibit a higher likelihood of apathy, but a lower likelihood of agitation or aggression, anxiety, and abnormal motor behaviors (Schwertner et al., 2022).

When giving a diagnosis of either Major or Mild Vascular Neurocognitive Disorder, the psychologist has established that the criteria for Major or Mild Neurocognitive Disorder have been met and the clinical features are consistent with a vascular etiology. There must be evidence of the presence of cerebrovascular disease either from history, physical exam, or neuroimaging and the deficits are not better accounted for by another brain disease or systemic disorder. If clinical criteria are supported by either neuroimaging evidence of significant parenchymal injury attributed to cerebrovascular disease, symptoms are temporally related to the cerebrovascular event, or both clinical and genetic evidence of cerebrovascular disease is present, then Probable Vascular Neurocognitive Disorder is diagnosed, otherwise Possible Vascular Neurocognitive Disorder is diagnosed. Table 7 summarizes the DSM-5-TR diagnostic criteria for Major Vascular Neurocognitive Disorder (American Psychiatric Association, 2022):

Table 7. DSM-5-TR Diagnostic Criteria for Major Vascular Neurocognitive Disorder

 

Criterion	Description
A. Evidence of a Major or Mild Neurocognitive Disorder	There is evidence of a significant (major) or modest (mild) decline in one or more cognitive domains (e.g., complex attention, executive function, memory, language, perceptual-motor, or social cognition) based on: Concern of the individual, informant, or clinician; and Substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing.
B. Vascular Etiology of the Cognitive Deficit	The clinical features are consistent with a vascular cause, as suggested by either or both of the following: Onset of cognitive deficits is temporally related to one or more cerebrovascular events (e.g., stroke). Evidence for decline prominent in complex attention (including processing speed) and frontal-executive function.
C. Evidence of Cerebrovascular Disease	There is evidence of cerebrovascular disease (from history, physical exam, or neuroimaging) that is sufficient to account for the neurocognitive deficits.
D. Not Better Explained by Another Disorder	The symptoms are not better explained by another brain disease or systemic disorder (e.g., Alzheimer’s disease, delirium, major psychiatric disorder).
E. Functional Impairment (for Major NCD only)	For Major Vascular NCD, the cognitive deficits interfere with independence in everyday activities. For Mild Vascular NCD, independence is preserved, though greater effort or compensatory strategies may be needed.

 

Frontotemporal Dementia (FTD)

Frontotemporal dementia (FTD) encompasses a group of clinical syndromes characterized by progressive alterations in behavior, executive functioning, or language abilities (Antonioni et al., 2023; Boeve et al., 2022). It typically presents with an insidious onset and a gradually progressive course. FTD is further classified into two main subtypes: behavioral variant frontotemporal dementia (bv FTD) and primary progressive aphasia (PPA) (Puppala et al., 2021). FTD typically has a younger onset, with a mean age at diagnosis of 56 years, and is the most common type of cognitive decline in people under the age of 65 (Antonioni et al., 2023).

FTD is frequently misidentified as a primary psychiatric condition – such as schizophrenia, bipolar disorder, or major depression – particularly when symptoms first emerge in younger adults. The disorder features a combination of personality and behavioral changes, including disinhibition, social withdrawal, inappropriate or antisocial behavior, and repetitive or compulsive actions, along with executive functioning deficits like poor planning, impaired judgment, and diminished insight. These clinical features often resemble those of psychiatric illnesses, contributing to diagnostic confusion (Onyike & Diehl-Schmid, 2013; Tampi, Tampi, & Parish, 2020). Compared to other dementias, individuals with FTD more commonly present with apathy, disinhibition, and alterations in appetite and eating patterns, and are less likely to display delusions, hallucinations, or depression/dysphoria (Schwertner et al., 2022).

Lewy Body Dementia

Lewy body dementia (LBD) is a progressive neurodegenerative condition marked by the abnormal buildup of Lewy bodies – clumps of the protein alpha-synuclein – in brain cells, which interferes with normal neurological functioning (Prasad et al., 2023). LBD encompasses both Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB). DLB is considered the second most common form of degenerative dementia in individuals over age 65 (Walker et al., 2015). Its defining pathological feature is the widespread presence of Lewy bodies throughout the cerebral cortex and subcortical gray matter (Fei et al., 2022). Research suggests that disruptions in the cholinergic and monoaminergic neurotransmitter systems contribute to the characteristic cognitive impairments and motor symptoms seen in DLB (McKeith et al., 2017). Clinically, DLB typically presents with early cognitive decline, often accompanied by recurrent visual hallucinations. Key cognitive deficits may include impairments in attention, executive function, and visuoperceptual abilities, sometimes appearing before significant memory loss (McKeith et al., 2017). Despite its prevalence, DLB remains substantially underdiagnosed, with postmortem studies revealing a considerable gap between clinical and neuropathological diagnoses (Palmqvist et al., 2009; Prasad et al., 2023).

DLB and PDD are clinically similar disorders that share key neuropathological features, including α-synuclein accumulation within Lewy bodies and neurites, degeneration of tegmental dopaminergic neurons, and loss of basal forebrain cholinergic neurons (Gomperts, 2016). The primary clinical distinction between DLB and PDD lies in the timing of dementia onset relative to parkinsonism: in PDD, dementia develops after at least one year of established Parkinson’s disease, whereas in DLB, cognitive impairment occurs before or concurrently with the onset of parkinsonian motor symptoms. Clinically, both conditions are characterized by progressive cognitive decline accompanied by parkinsonism, visual hallucinations, fluctuations in attention and alertness, and REM sleep behavior disorder (Gomperts, 2016; McKeith et al., 2017).

Training in Geropsychology

Pikes Peak Model

The primary framework for geropsychology training is the Pikes Peak Model for Training in Professional Geropsychology (Knight et al., 2009), which provides the foundation for developing competence in psychological practice with older adults across all care environments, including long-term care (LTC). The model outlines essential competencies in attitudes, knowledge, and skills that trainees are expected to build progressively over the course of their education and professional development. These competencies serve as a roadmap for both emerging and practicing psychologists to ensure effective, ethical, and age-informed clinical work. In alignment with the Pikes Peak Model and recommendations from the Council of Professional Geropsychology Training Programs (CoPGTP, 2016); Hinrichsen et al., 2018), comprehensive descriptions of the foundational knowledge competencies have been published to support generalist psychologists in enhancing their work with older adults (Hinrichsen & Emery-Tiburcio, 2022). As summarized in Table 8, these five foundational domains include Attitudes Toward Older Adults (Garrison-Diehn et al., 2022), Adult Development and Aging (Woodhead & Yochim, 2022), Clinical Practice (Jacobs & Bamonti, 2022), Assessment (Mast, Lichtenberg, & Fiske, 2022), and Intervention, Consultation, and Other Service Provision (Lind et al., 2022).

Table 8. Geropsychology Knowledge Competency Domains with Key Topics

 

Domain	Key Topics
Attitudes Toward Older Adults (Garrison-Diehn et al., 2022)	Historical context of ageism and how attitudes toward older adults and aging have evolved. The role of attitudes about aging in older-adult health and behavioral health. Diversity among older adults and acknowledging variation in age, culture, identity, gender, disability, and life experience. Research on the impact of stereotypes and attitudes (positive and negative) toward aging on outcomes. Practical implications for psychologists: strategies for increasing knowledge, improving attitudes, and enhancing skills when working with older adults.
Adult Development and Aging (Woodhead & Yochim, 2022)	Demographic shifts and the aging population: overview of why adult development and aging are increasingly important for clinical practice. Diversity in the aging process: variation by cohort, culture, gender, socioeconomic status, and other individual differences. Research methods in aging: key methodological issues, e.g., disentangling age, cohort, and period effects; longitudinal vs cross-sectional designs. Theoretical frameworks of aging and adult development: major models that inform our understanding of change across adulthood. Age-related changes in physical and health domains: how aging affects physical health, biological systems, and implications for practice. Social development across adulthood: changes in social roles, relationships, work/retirement, and how these impact older adult functioning. Personality and emotional development in aging: stability vs change, emotional regulation, and personality growth or decline in later years. Cognitive aging: normative changes in cognition (e.g., fluid vs crystallized abilities), as well as implications for assessment and treatment in aging populations. Application to clinical psychology: using knowledge about adult development and aging to inform case conceptualization, treatment planning, and intervention with older adults.
Assessment (Mast et al., 2022)	Foundational knowledge for assessment with older adults Core assessment domains in geropsychology Risk assessment specific to older adults Selection and use of assessment instruments Contextual and methodological issues in assessment with older adults Integration into comprehensive geropsychological practice
Clinical Practice (Jacobs & Bamonti, 2022)	Psychopathology in late life Mental Disorders That Decline Over the Lifespan Mental Disorders That Increase Over the Lifespan The Neuroscience of Cognitive Aging Structural and Functional Changes in Normal Aging Cognitive Change in Pathological Aging Structural and Functional Changes in Pathological Cognitive Aging Impact of Cognitive Aging on Clinical Interventions Functional Changes in Late Life Common Medical Illnesses in Late Life Person-Environment Interaction and Adaptation in Late Life
Intervention, Consultation, and Other Service Provision (Lind et al., 2022)	Evidence-based treatments for older adults Interventions for individuals with cognitive impairment Health, illness, and Psychopharmacology Provision of service in specific settings Ethical and legal standards Detecting and reporting elder abuse and neglect

 

Geropsychology Foundational Knowledge Competency Domains

Attitudes Toward Older Adults

Garrison et al. (2022) highlight central themes related to attitudes toward older adults and the aging process, a key knowledge domain within the Pikes Peak geropsychology competencies. They emphasize that both patient and provider attitudes meaningfully affect many aspects of behavioral health care. Because older adults are an exceptionally diverse population, with wide differences in functioning, backgrounds, and identities, it is critical for clinicians to consider each person’s unique characteristics as well as the historical and sociocultural context that has shaped their life.

Although aging unfolds differently for every individual, negative stereotypes and biased assumptions about older adults remain widespread across many societies, including within healthcare environments (Wyman et al., 2019). These common stereotypes – portraying older adults as forgetful, frail, incompetent, ill, burdensome, senile, or unattractive – unfortunately reinforce ageism. Such beliefs influence perceptions and treatment of older adults and foster discriminatory attitudes, marginalization, and unequal opportunities throughout later life.

Beyond negative stereotypes, overly positive assumptions about older adults can also be damaging. Benevolent ageism describes attitudes or behaviors that may appear kind or well-meaning but are ultimately paternalistic, condescending, or exclusionary (Dossing & Craciun, 2022). This subtle form of ageism reinforces the idea that older adults are warm, sweet, and lovable, while simultaneously portraying them as fragile, dependent, or less capable. Such assumptions can lead clinicians to overlook each person’s individuality, miss important clinical details, or interact in overly protective or patronizing ways. Communication patterns like elderspeak can further increase dependency, withdrawal, and resistance to care; however, provider education and greater awareness can reduce these behaviors and strengthen therapeutic relationships.

Given the significant negative impact ageism can have on older adults, psychologists working with them are encouraged to reflect on their own beliefs and assumptions about aging. This practice aligns with Guideline 2 of the Guidelines for Psychological Practice with Older Adults (American Psychological Association, 2024), which highlights the importance of recognizing how personal attitudes can shape clinical judgment, assessment, and intervention. Instruments such as the Pikes Peak Geropsychology Knowledge and Skill Assessment Tool (Council of Professional Geropsychology Training Programs, 2016; Karel et al., 2010) and the Fraboni Scale of Ageism (Fraboni et al., 1990) offer structured ways to identify areas for improvement and evaluate age-related biases. When used alongside supervision or consultation with a geropsychology mentor or colleague, these tools can deepen self-awareness, support ongoing professional growth, and foster more competent and equitable care for older adult clients.

People looking to shift their attitudes toward aging can benefit from evidence-based strategies that emphasize education about the aging process and meaningful interactions with older adults. Persistent ageist beliefs are often reinforced by limited exposure to geropsychology in graduate and professional training, where aging receives little emphasis across psychology and other health disciplines. Negative portrayals of older adults in mass media further perpetuate stereotypes. Efforts such as the Reframing Aging Initiative Reframing Aging > NCRA Home) work to address these biases by offering educational tools and promoting more accurate, strengths-based representations of aging for both professionals and the broader public.

Garrison et al. (2022) highlight several important practice considerations for working effectively with older adults, including ongoing self-reflection about one’s own beliefs and biases, expanding knowledge of normative aging, and fostering meaningful interactions with older adults outside of clinical roles. They recommend seeking supervision or mentorship from geropsychology specialists, practicing within one’s professional boundaries, and avoiding infantilizing communication such as elderspeak. Clinicians are also encouraged to openly address sensitive topics, including sexuality and suicide, and to recognize that even seemingly positive stereotypes can undermine person-centered, respectful care.

Adult Development and Aging

The Pikes Peak Model of Training in Professional Geropsychology emphasizes the importance of general knowledge about adult development and aging as a foundation for effective practice. Woodhead and Yochim (2022) provide an overview of the demographics of the aging population, the diversity of the aging process, relevant research methods, and key theories of aging. They also review age-related changes in physical health, social relationships, personality, and emotional development. Understanding these aspects of adult development and aging supports effective conceptualization, treatment planning, and the interpretation of older adults’ presenting concerns within the broader context of age-related changes.

In 2022, individuals 65 years and older represented 17.3% of the population in the United States and that percentage is expected to grow to 22% by 2040 (Administration for Community Living, 2025). By 2034, older adults aged 65 and over will outnumber children under 18 in the United States (Medina et al., 2020). The older adult population is growing more diverse, with 34% projected to identify as part of a racial or ethnic minority group by 2040 (Woodhead & Yochim, 2022). Most older adults remain in their own homes, although the likelihood of living alone or in congregate settings rises with age (Roberts et al., 2018). In 2022, approximately 1.3 million people aged 65+ lived in nursing homes (Administration for Community Living, 2024). Life expectancy is also increasing and is projected to reach 85.6 years by 2060, with the largest improvements anticipated among Black and American Indian or Alaska Native populations (Medina et al., 2020). In 2017, Hispanic women and men had the highest life expectancies, whereas Black and American Indian or Alaska Native individuals had the lowest; however, these latter groups are expected to experience the most substantial gains by 2060.

Older adults represent an increasingly diverse population, differing in race, gender identity, sexual orientation, language, religion, and socioeconomic background. This diversity is best understood through an intersectional lens, recognizing how overlapping identities – such as age, race, and gender – create cumulative disadvantages that affect health and longevity. Experiences of systemic racism and discrimination across the lifespan contribute to disparities in physical and mental health among racial and ethnic minority older adults, particularly Black Americans, and can lead to mistrust in healthcare and other services. Mental health providers should take into account the significance of diversity (race, ethnicity, gender identity, sexual orientation, socioeconomic status, rural/urban residence) and the role of intersectionality (how multiple identities combine) in shaping older adults’ development and health outcomes (Woodhead & Yochim, 2022).

It is important for mental health providers to be aware that many “normal aging” changes exist, but also that older adults may face unique risk factors (e.g., cumulative disadvantage, discrimination, health disparities) that affect how they age and how they respond to interventions. It is important to understand adult development and aging to support case conceptualization and treatment planning, in other words, to help see older clients’ presenting problems in the broader context of normative and variable aging processes. Therefore, it is advantageous to conceptualize psychological treatment for older adults through the framework of lifespan developmental theories, including Erikson’s (1982) Stages of Psychosocial Development, Carstensen’s (1992) Socioemotional Selectivity Theory, and Baltes and Baltes’ (1990) model of Selective Optimization with Compensation. These theoretical perspectives assist psychologists in providing targeted interventions that account for age-related changes, foster emotionally meaningful connections, and promote positive emotional well-being in later life. In addition, models such as the Family Systems Model (Segal et al. , 2018) and the Contextual Adult Lifespan Theory for Adapting Psychotherapy (Knight & Poon, 2008) offer important frameworks for integrating developmental, sociocultural, contextual, historical, generational, and familial influences into clinical practice.

Assessment With Older Adults

Mast and colleagues (2022) stress that assessing older adults is a fundamental geropsychology competency that demands specialized expertise, clinical sensitivity, and continual professional development. They highlight key principles including the use of age-appropriate instruments, consideration of cohort and cultural factors, functional and risk-based assessment, and attention to the interaction of medical, cognitive, emotional, and environmental influences.

Geropsychological assessment necessitates the use of assessment measures that are appropriate and validated for older adults. In addition to using measures that are normed for older adults, the issue of normative data extends beyond age and requires consideration of how factors such as language, culture, ethnicity, socioeconomic status, and reading ability can influence test performance. Assessments should also be adapted for sensory, cognitive, or physical changes that may affect performance.

Adopting a person-centered approach that prioritizes the perspectives of individuals living with cognitive impairment and dementia is important (Mast, 2011; Mast et al., 2021; Mast et al., 2022; Molony et al., 2018). Traditionally, providers have overlooked these perspectives due to the mistaken belief that people with dementia cannot reliably express their experiences, needs, values, or preferences. However, Mast and colleagues (2022) have identified numerous self-report measures with strong psychometric support for use among individuals with dementia, assessing areas such as hope, psychological well-being, meaning, resilience, spirituality, social support, stigma, and care preferences. Many of these instruments are suitable for use with both cognitively healthy older adults and those with impairment. For example, the Geriatric Depression Scale (Yesavage et al., 1983), Cornell Scale for Depression in Dementia (Alexopoulos et al., 1988), and Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001; Kroenke & Spitzer, 2002) can be used to assess depressive symptoms among older adults. To assess for anxiety, the Geriatric Anxiety Inventory (Pachana et al., 2007), Geriatric Anxiety Scale (Segal et al., 2010), and Rating Anxiety in Dementia (RAID) (Shankar et al., 1999) are instruments that can be utilized with older adults. Measures that can be used to assess suicide risk with older adults include the Geriatric Suicide Ideation Scale (GSIS) (Heisel & Flett, 2006), Scale for Suicide Ideation (SSI) (Beck et al., 1979b), Beck Hopelessness Scale (BHS) (Beck et al., 1974), and Geriatric Hopelessness Scale (GHS) (Heisel & Flett, 2005). The reader is referred to Mast et al. (2022) for a more complete list of assessment measures.

Psychologists who work with older adults may be asked to evaluate decision-making capacity by determining whether cognitive or mental health conditions interfere with the specific capacity in question. Because capacity is defined by state law, the standards vary for areas such as guardianship, sexual consent, and medical decisions. A finding of incapacity requires clear evidence that an underlying condition is directly impacting the specific decision-making ability (Mast et al., 2022). Effective capacity assessment goes beyond diagnosing impairment; it also requires determining the individual’s understanding of information relevant to the decision, appreciation of how that information applies to one’s own situation, reasoning about possible options and consequences related to the decision, and the ability to clearly and consistently express a choice (American Bar Association Commission on Law and Aging & American Psychological Association, 2008; Appelbaum & Grisso, 1988). Readers seeking more in-depth guidance on decisional capacity, such as the foundational abilities of understanding, appreciation, reasoning, and expressing a choice, can consult Lichtenberg and Mast’s (2015) APA Handbook of Clinical Geropsychology. This resource provides detailed discussion of conceptual models, assessment tools, evaluation of functional abilities, the influence of contextual and cultural factors, and the impact of neurocognitive disorders on capacity. Additional key references for psychologists conducting capacity evaluations include the ABA/APA Handbook of Assessment of Diminished Capacity of Older Adults (American Bar Association Commission on Law and Aging & American Psychological Association, 2008) and Moye’s (2020) casebook, which offers practical case examples illustrating complex capacity-related issues.

The American Psychological Association’s (APA) Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change (2021) provide guidance to promote proficiency and expertise in evaluating dementia and age-related cognitive decline using evidence-based assessment tools and techniques. Emphasis is made on practioners developing multicultural competence in assessments, including understanding the sociocultural factors that can influence cognitive health and access to care. The guidelines also highlight the importance of involving caregivers and family in the assessment process. The APA Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change (2021), which are broken down into general and procedural guidelines can be found in Appendix I. The reader is referred to APA (2021) for more detailed information on the Guidelines.

Clinical Practice with Older Adults

Clinical care of older adults presents distinct challenges because mental health conditions frequently co-occur with medical illnesses, functional limitations, and late-life stressors, all of which contribute to under-recognition and inadequate treatment. Jacobs and Bamonti (2022) provide an overview of the foundations of clinical practice with older adults. When working with older adults, age- and disease-related cognitive, sensory, and functional changes require thoughtful treatment modifications and a holistic, integrated approach to help older adults adapt to aging and support their overall well-being. It is important for mental health providers to integrate these intersecting factors when assessing symptoms and planning treatment, rather than viewing them in isolation. Assessment should go beyond diagnosis to evaluate functional abilities, including mobility, daily living skills, and independence, as understanding functional status helps guide treatment goals and care planning.

Older adults are less likely than younger individuals to report mental health concerns, often due to greater stigma surrounding mental illness and a tendency to attribute symptoms to medical conditions or other external factors. Clinicians must be mindful of this tendency, prioritize building strong rapport, and rely on validated screening tools to help identify mental health conditions that may otherwise go unrecognized. Clinicians should be alert to atypical presentations and avoid misattributing psychological symptoms to “normal aging.” Jacobs and Bamonti (2022) have noted that risk factors for late life anxiety and depression include undergoing role changes (e.g., taking on a role of caregiving), change in living arrangement or setting, chronic medical illness or disease, self-perceived poor health, functional decline, decreased autonomy, financial strain, forced retirement due to illness or disability, loss of a loved one (particularly a spouse), loneliness, perception of poor social support, perception of excessive or unhelpful support, and being unmarried. In addition, they note that protective factors include being from higher socioeconomic status, good health, improved emotional regulation, increased focus on positive stimuli, decreased focus on negative stimuli, positive self-concept, high self-efficacy, good social support, physical exercise, religious involvement, and engagement in meaningful activities.

Most mental health disorders become less common with increasing age (Byers et al., 2010; Pang et al., 2025; Reynolds et al., 2015). Prevalence rates of depressive, anxiety, personality, schizophrenia-spectrum, and bipolar disorders are generally lower among older adults than among younger and middle-aged adults (Byers et al., 2010; Cohen et al., 2018; Collier et al., 2023; Depp & Jeste, 2004; Fiske et al., 2009; Reynolds et al., 2015). While substance use disorders (SUDs) become less common with age, they have shown a notable increase over the past decade as the baby boomer cohort, whose lifetime rates of substance use were higher than previous generations, has entered older adulthood (Kuerbis, 2020).

Providers should recognize how mental health conditions interact with age-related experiences, including physical decline, functional limitations, and changes in social or occupational roles. Because normative cognitive shifts occur with aging, all clinicians need a basic understanding of typical patterns of cognitive aging as well as the warning signs of pathological decline, such as dementia. It is also essential to appreciate how an older adult’s environment, including their home, neighborhood, and available supports, shapes mental health and daily functioning, and to incorporate these contextual factors into case conceptualization to evaluate overall person-environment fit. Providers can support older adults’ well-being by providing interventions that enhance their sense of control and self-efficacy, empowering them to make changes to modifiable aspects of their environment.

Intervention, Consultation, and Other Service Provision

Lind and colleagues (2022) outline essential knowledge and skills that mental health providers need to provide effective interventions, consultation, and other psychological services with older adults. Effective psychological care for older adults relies on a solid grasp of the foundational domains of geropsychology, as well as an appreciation for the cultural, contextual, and generational (cohort) influences that shape treatment outcomes. Research has consistently shown that psychotherapy is beneficial for older adults (Raue et al., 2017; Scogin, 2007; Scogin & Shah, 2012; Tavares & Barbosa, 2018). In fact, older adults have shown better outcomes from psychological treatments than working-age adults (Saunders et al., 2021). Nonetheless, the distinct features of aging can affect both the delivery and the experience of therapeutic interventions with older adults. Psychologists often need to adjust the content, pacing, and frequency of interventions for older adults to account for aging-related challenges. Tailoring treatment begins with understanding each client’s cognitive strengths and limitations, along with their core values, so that therapeutic approaches can be modified appropriately. A solid grasp of both normative and non-normative biological and cognitive aging, and awareness of how medical and mental health symptoms can overlap, enables providers to develop individualized, biopsychosocial treatment plans that effectively address the unique needs of older adults.

Evidence-Based Treatments for Older Adults

The American Psychological Association’s Presidential Task Force on Evidence-Based Practice (2006) emphasized the need to integrate the best available research with clinical expertise and to account for client characteristics, culture, and preferences when making treatment decisions. Consistent with these principles, the APA’s Society of Clinical Geropsychology (SGC) initiated efforts to identify evidence-based treatments (EBTs) for older adults, following criteria outlined by the Society of Clinical Psychology (Chambless et al., 1996). These initiatives led to a special section in Psychology and Aging devoted to Evidence-Based Psychological Treatment for Older Adults (Scogin, 2007). Since then, research has continued to expand, demonstrating the effectiveness of psychological interventions for older adults across a wide range of mental health conditions, including mood and anxiety disorders, posttraumatic stress disorder, schizophrenia and other late-life psychoses, sexual dysfunction, sleep disturbances, chronic pain, substance use disorders, and personality disorders (Edelstein et al., 2015; Raue et al., 2017; Scogin & Shah, 2012; Segal et al., 2018). For example, several evidence-based psychological treatments for geriatric depression have been identified as beneficial, including behavioral therapy, cognitive behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and reminiscence therapy (Scogin et al., 2005). For a more in-depth review of interventions addressing these conditions, readers are encouraged to consult The APA Handbook of Clinical Geropsychology, (Lichtenberg & Mast, 2015) and Aging and Mental Health (Segal et al., 2018). The following section provides a brief overview of key evidence-based psychotherapeutic approaches commonly used with older adults in both individual and group formats.

Brief Psychodynamic Therapy (BPT)

BPT focuses on increasing clients’ insight into how early life experiences influence their current thoughts, emotions, and behaviors. Typically delivered in 10 to 25 sessions, BPT employs techniques such as reflection, interpretation, and exploration of maladaptive relationship patterns, internal conflicts, and defense mechanisms (Messer, 2006). Empirical evidence supports BPT as an evidence-based treatment (EBT) for depression among older adults (Fiske et al., 2009; Samad, Brealey, & Gilbody, 2011; Scogin et al., 2005; Thompson et al., 1987) and for family caregivers experiencing depression (Gallagher-Thompson & Steffen, 1994). Moreover, longitudinal research has shown BPT to be effective in alleviating late-life depression (Roseborough et al., 2013). Nonetheless, additional studies with larger and more diverse samples, as well as more rigorous methodologies, are needed to further solidify its empirical foundation.

Behavioral Therapy

Behavioral therapy (BT) encompasses a broad set of interventions rooted in learning theory and behavior-change principles that help older adults acquire new coping skills, reduce unhelpful or avoidant behaviors, and increase engagement in pleasurable or meaningful activities. By addressing patterns of avoidance, withdrawal, and inactivity, BT increases positive reinforcement and helps reduce depressive symptoms (Polenick & Flora, 2013). Extensive research supports BT’s effectiveness in treating depression among older adults (Gallagher & Thompson, 1982; Haringsma et al., 2006; Rokke et al., 1999; Samad et al., 2011; Teri et al., 1997; Thompson et al., 1987), benefiting both those with subclinical symptoms and individuals diagnosed with Major Depressive Disorder (Shah et al., 2012). A notable example is the Behavioral Activities Intervention (BE-ACTIV) (Meeks et al., 2008; Meeks et al., 2019), which applies behavioral activation principles to reduce depression in cognitively intact nursing home residents. Additionally, various exposure-based therapies, including imaginal, in vivo, interoceptive, virtual reality exposure, exposure with response prevention, and prolonged exposure, have demonstrated efficacy in treating anxiety disorders, OCD, and PTSD in older adults, either independently or as components of cognitive-behavioral therapy (Jayasinghe et al., 2017). For late-life insomnia, Sleep Restriction-Sleep Compression has also been identified as an evidence-based and effective intervention (McCurry et al., 2007).

Behavior therapy is particularly well suited for older adults because it is structured, goal-oriented, and adaptable to individuals with medical comorbidities, chronic pain, mobility limitations, or cognitive impairment. Its emphasis on small, achievable steps aligns well with geriatric principles of pacing, environmental modification, and compensatory strategies.

Cognitive Therapy

Cognitive therapy (CT) is a structured, time-limited treatment that focuses on identifying and modifying maladaptive thoughts, beliefs, and cognitive distortions that contribute to emotional distress and dysfunctional behavior. Treatment involves helping clients recognize automatic thoughts, evaluate their accuracy, and replace them with more balanced and adaptive cognitions, often combined with behavioral techniques to test new beliefs in real-life situations (Beck et al, 1979a). This collaborative, goal-oriented approach has strong empirical support in treating a range of psychological issues in older adults, particularly depression, anxiety, and substance use disorders (Gallagher-Thompson et al., 2008; Pary et al., 2019; Thoma et al., 2015). One variation, known as cognitive bibliotherapy, where CT is delivered through self-help books incorporates psychoeducational elements such as reading materials and structured homework assignments. This approach has been identified as an evidence-based treatment (EBT) for depression in older adults (Shah et al., 2012). A systematic review and meta-analysis of randomized controlled trials in older adults found that cognitive-based interventions, including cognitive therapy, were moderately effective in improving cognitive functioning, particularly among healthy older adults or those with mild cognitive impairment (Yun & Ryu, 2022).

Cognitive Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) encompasses a range of therapeutic approaches designed to address the influence of maladaptive thought patterns on emotions and behavior (Ghaed et al., 2012). It combines behavioral techniques, such as behavioral activation and relaxation training, with cognitive strategies that help individuals identify, challenge, and reframe unhelpful thoughts (Shah et al., 2012). CBT is one of the most empirically supported psychotherapies and has demonstrated effectiveness across disorders such as depression, anxiety, insomnia, chronic pain, and medical comorbidities, including in older adult populations (Laidlaw et al., 2003; Hofmann et al., 2012). Randomized controlled trials (RCTs) and meta-analyses consistently show that CBT leads to significant reductions in depressive symptoms among older adults (Pinquart & Duberstein, 2007; Shah et al., 2012). Numerous studies have consistently demonstrated that CBT leads to significant reductions in depressive symptoms among older adults (Bilbrey et al., 2020; Campbell, 1992; Floyd et al., 2004; Gallagher & Thompson, 1982; Karlin et al., 2015).

In addition to its well-established use for depression, CBT has proven effective in treating a variety of other mental health conditions in later life, including anxiety disorders (Andreescu & Varon, 2015; Ayers et al., 2007; Bower et al., 2015; Gorenstein et al., 2005; Hall et al., 2016), insomnia (Ludwin et al., 2018; McCurry et al., 2007; Rybarczyk et al., 2005; Vitiello et al., 2009), and chronic pain (Niknejad et al., 2018; Vitiello et al., 2009). Research shows that CBT remains effective for older adults even when significant medical comorbidities are present (Cuijpers et al., 2014; Williams, Johnston, & Paquet, 2020). Overall, CBT represents the most extensively studied and empirically supported psychotherapeutic approach for addressing psychological distress and promoting well-being among older adults (Segal et al., 2018).

Problem-Solving Therapy

Problem-Solving Therapy (PST) is based on the idea that difficulties adapting to or managing stressful life situations can increase vulnerability to mental health concerns. PST aims to enhance individuals’ practical coping skills so they can navigate challenges more effectively (Nezu et al., 2015). Using a structured, step-by-step approach, older adults are guided to define problems clearly, set attainable goals, brainstorm possible solutions, choose and implement a strategy, and evaluate the results. PST is a well-supported, evidence-based intervention for late-life depression among older adults with mild cognitive impairment, significant medical comorbidities, and physical limitations, and it can be delivered effectively in primary care and other non-specialty settings (Arean & Huh, 2006). Evidence from diverse settings, including long-term care facilities, community-based programs, and home-delivered services, shows that PST reliably reduces depressive symptoms in older adults (Shah et al., 2012). When working with older adults, clinicians often modify PST by slowing the pace of sessions, simplifying materials, and drawing on the rich life experience and practical knowledge that older clients bring to treatment. By helping individuals break complex or overwhelming challenges into manageable, step-by-step tasks, PST teaches a more deliberate and structured approach to coping (Arean & Huh, 2006).

Reminiscence Therapy

Reminiscence Therapy (RT) is based on Erikson’s (1982) psychosocial theory, particularly the final stage of ego integrity versus despair, which emphasizes reflecting on one’s life to foster coherence, acceptance, and a sense of fulfillment. This reflective process can help older adults find meaning and emotional resolution as they age. RT interventions typically involve storytelling and the sharing of past experiences (Moon & Park, 2020) and are commonly grouped into three formats: simple or unstructured reminiscence, structured reminiscence (often referred to as life review), and highly structured life review therapy (Webster et al., 2010). The most structured approach guides participants through key life periods using focused prompts to help them extract meaning from earlier experiences and apply those insights to present-day concerns (Korte et al., 2012). Empirical research demonstrates that life review interventions can significantly alleviate depressive symptoms in both individual and group therapy settings (Alqam, 2018; Edelstein et al., 2015; Korte et al., 2012; Serrano et al., 2004). Moreover, structured reminiscence therapies have proven effective in reducing depression among nursing home residents, supporting their use as evidence-based interventions for enhancing emotional well-being in late life (Chiang et al., 2010; Haight et al., 2000).

Interpersonal Psychotherapy

Interpersonal Psychotherapy (IPT) is not yet formally classified as an evidence-based treatment for older adults, but it is recommended as a first-line option for managing late-life depression, often alongside pharmacotherapy (APA, 2019). Developed by Klerman and colleagues (1984), IPT is a time-limited therapy grounded in a biopsychosocial approach that recognizes how stressful or adverse life events can intensify feelings of sadness, loss, and low self-esteem (Weissman et al., 2017).

The primary aim of IPT is to enhance current interpersonal functioning by helping individuals express emotions more effectively, improve communication patterns, and develop better problem-solving skills within significant relationships (Hinrichsen, 2008; Hinrichsen & Clougherty, 2006). Treatment typically centers on four core areas – grief, role disputes, role transitions, and interpersonal deficits – which align closely with common relational and developmental issues experienced in later life (Hinrichsen, 2008). IPT has also been adapted to help reduce suicide risk among older adults, further highlighting its value in geriatric mental health care (Heisel et al., 2015).

Group Therapy

Group Therapy is a well-established, evidence-based intervention for older adults (Agronin, 2009). Group formats of cognitive-behavioral therapy (CBT) and Life Review/Reminiscence Therapy are both recommended for treating late-life depression (APA, 2019). Group-based CBT for insomnia (CBT-I) has also shown strong effectiveness with older adults (Ludwin et al., 2018), and studies demonstrate that both standard CBT-I and CBT-I enhanced with positive mood components (CBT-I+) produce significant improvements in insomnia and depressive symptoms compared with psychoeducational controls (Sadler et al., 2018).

Group reminiscence therapy has been found to benefit older adults with Alzheimer’s disease by enhancing mood, cognitive functioning, daily activities, and overall quality of life (Cuevas et al., 2020). Additionally, Meaning-Centered Men’s Groups (MCMG) have effectively reduced depression, hopelessness, and suicidal ideation among men facing the transition to retirement (Heisel et al., 2015). Taken together, group CBT, group life review, and group problem-solving therapy (PST) all have strong empirical support and are recommended treatments for depression in older adults (APA, 2019).

Since this course cannot fully address all mental health interventions relevant to later life, readers are encouraged to consult more comprehensive resources, such as the APA Handbook of Clinical Geropsychology (Lichtenberg & Mas, 2015) and Aging and Mental Health, 3rd ed. (Segal et al., 2018), for more in-depth coverage.

Interventions for Individuals with Cognitive Impairment or Dementia

A range of therapeutic interventions have demonstrated effectiveness for older adults with cognitive impairment or dementia. The APA’s Clinical Practice Guideline (2019) conditionally recommends individual Problem-Solving Therapy (PST), Problem-Solving Behavioral Therapy, and Pleasant Events Behavioral Therapy for older adults with depression and cognitive decline. PST, in particular, is supported for individuals with executive dysfunction and has been shown to reduce disability more effectively than supportive therapy (Arean et al., 2010). Adaptations such as Problem Adaptation Therapy (PATH), a home-based, caregiver-supported PST model, have been associated with meaningful improvements in depressive symptoms and daily functioning among older adults with comorbid depression, cognitive impairment, and disability (Kanellopoulos et al., 2020). Interpersonal Psychotherapy has also been modified for this population (IPT-ci), incorporating caregiver assistance to strengthen coping and address relational challenges associated with cognitive decline (Miller, 2009; Miller & Reynolds, 2007).

Behavioral and cognitive-behavioral interventions are effective across varying degrees of cognitive impairment. Behavioral activation is considered a strong first-line treatment for late-life depression, including among older adults with dementia (Bilbrey et al., 2020; Teri et al., 1997), with benefits sustained at follow-up. CBT for insomnia (CBT-I) has been shown to improve both sleep and executive functioning in older adults with mild cognitive impairment (Cassidy-Eagle et al., 2018).

Managing behavioral symptoms in dementia often requires individualized, function-based approaches. Effective strategies draw from learning theory, person-environment fit models, and the need-driven behavior model (Curyto et al., 2012). Interventions that identify antecedents and behavioral functions – such as the STAR-VA program – have been successful in reducing disruptive behaviors in long-term care settings (Karlin et al., 2014). Additional evidence-based supports include caregiver and staff training (Lichtenberg et al., 2005; Proctor et al., 1999; Teri et al., 1997, 2005), peer support groups (Visser et al., 2008), simulated presence therapy (Camberg et al., 1999; Garland et al., 2007), and structured activity programs (Rovner et al., 1996; Volicer et al., 2006).

Therapy with cognitively impaired older adults often requires thoughtful adaptation. Clinicians should consider developmental, sociocultural, and contextual factors (Knight & Poon, 2008) and tailor interventions by adjusting session pacing, simplifying material, and aligning treatment with the client’s cognitive strengths, limitations, and core values. Modifications may include the use of large-print or audio materials, visual aids, and external memory supports (e.g., calendars, alarms), as well as environmental adjustments to improve communication – such as reducing background noise, speaking slowly and clearly, or positioning oneself closer to the client (APA, 2024). For clients with memory impairment, gradual presentation of material, frequent demonstration, repetition, and in-session practice can enhance learning and retention. For those with executive dysfunction, adaptations such as using concrete examples, offering multiple-choice prompts, and summarizing content in bullet points may improve comprehension and follow-through. Involving family caregivers or staff – particularly for activity scheduling or homework practice – can further support treatment engagement and effectiveness (Bilbrey et al., 2020).

Health, Illness, and Pharmacology

A strong understanding of both normative and non-normative biological and cognitive aging, as well as common medical conditions, enables psychologists to develop individualized, biopsychosocial treatment plans for older adults (APA, 2014). Because medical and psychological symptoms often overlap, clinicians must recognize how chronic illnesses influence mental health. Depression in later life is strongly associated with multiple comorbidities such as diabetes, obesity, metabolic syndrome, osteoarthritis, respiratory disease, Parkinson’s disease, cancer history, and overall multimorbidity (Agustini et al., 2020), and it can further impair adherence to medical treatments (Law et al., 2014; McMurray et al., 2020). Understanding the bidirectional relationship between physical illness and emotional distress helps psychologists support older adults in reframing symptoms and adapting to health-related challenges.

Knowledge of delirium is essential, as it represents an acute and often reversible change in cognition and behavior linked to underlying medical causes. Symptoms such as inattention, agitation, hallucinations, and delusions (Anand & MacLullich, 2021; Marcantonio, 2017) require immediate referral and evaluation. Common contributors – including infections, dehydration, electrolyte imbalances, medication withdrawal, pain, and sleep disruption – are especially prevalent in hospital and long-term care settings (Kalish et al., 2014; Kennedy et al., 2020). Psychologists should therefore avoid making new psychiatric diagnoses during acute illness given the potential for temporary cognitive changes.

Because older adults are more susceptible to medication side effects and polypharmacy, psychologists benefit from familiarity with commonly prescribed drugs, their interactions, and age-related changes in metabolism (Arnold, 2015). The AGS Beers Criteria (2019) provides helpful guidance on potentially inappropriate medications. Clinicians should be aware that certain drugs – such as corticosteroids, long-term opioids, and anticholinergic agents used for sleep or incontinence – can worsen mood, cognition, or treatment engagement (Labott, 2019; Samuelsen et al., 2017; Scherrer et al., 2014). This awareness equips psychologists to help clients explore non-pharmacological approaches for managing pain, sleep problems, and health-related distress and to collaborate effectively with medical providers.

Provision of Mental Health Services with Older Adults in Various Settings

Mental health professionals increasingly serve in expanded roles across integrated healthcare systems, providing both direct care and consultation while collaborating with interdisciplinary teams. Older adults access psychological services in a wide range of settings – including primary care clinics, hospitals, rehabilitation centers, VA and psychiatric units, skilled nursing facilities, assisted living, outpatient offices, private practices, and through home-based or telehealth services.

Primary care remains the most common entry point for older adults seeking mental health treatment (APA, 2008; Raue et al., 2017). In these settings, clinicians conduct behavioral health assessments and deliver brief, solution-focused interventions that support management of chronic medical conditions (Moye et al., 2019). Typical referral concerns include depression, anxiety, cognitive changes, insomnia, chronic pain, caregiver strain, bereavement, weight management, and substance use (APA, 2008). Providers in primary care benefit from familiarity with evidence-based treatments adapted for integrated care (Unutzer et al., 2002).

Older adults also receive care in inpatient units, long-term care (LTC) communities, and via telehealth. LTC encompasses a continuum of services – including short-term rehabilitation, nursing homes, assisted living, and memory care – designed for individuals with chronic or complex conditions that impair daily functioning. Although psychologists’ core competencies carry across healthcare environments, LTC presents unique challenges involving regulatory requirements, interdisciplinary coordination, and continuity of care. The need for psychological services is substantial; the Centers for Medicare & Medicaid Services (2016) reports that more than 1.4 million residents lived in U.S. nursing homes at the end of 2014, representing about 2.6% of adults aged 65+ and nearly 10% of those aged 85+.

Provision of Psychological Services in LTC Settings

The nursing home industry currently delivers essential medical and personal care services to roughly 1.3 million residents across about 15,300 facilities nationwide (Nursing Home Care Statistics in the U.S, 2025). However, the nursing home industry is confronting a major demographic shift that poses one of the greatest challenges in U.S. healthcare. Projections suggest the resident population could rise by as much as 75%, reaching approximately 2.3 million by 2030. This surge is largely driven by the aging Baby Boomer generation, whose oldest members are now entering the age group most likely to require long-term care (Nursing Home Care Statistics in the U.S, 2025).

The majority (84%) of long-term care residents are 65 and older, while more than one-third (39%) are 85 and older (Harris-Kojetin et al., 2019). Approximately 17% of long-term care residents are younger than 65 (Nursing Home Care Statistics in the U.S, 2025) and are the most rapidly growing age group in nursing homes (Jin & Agrawal, 2017). Younger adults, including those with traumatic brain injury (TBI), disabilities, or chronic medical and psychiatric conditions, or other health challenges requiring specialized care, now represent the fastest-growing segment of individuals in institutional long-term care (LTC) settings (Harris-Kojetin et al., 2019; Shapiro, 2010). Younger nursing home residents are more likely to be male, unmarried, and have lower educational attainment, and they are typically admitted from acute care, psychiatric, or rehabilitation hospitals (Persson & Ostwald, 2009).

Data from the National Post-acute and Long-term Care Study indicated the racial background of nursing home residents in 2022 as 70.8% non-Hispanic White, 15.7% non-Hispanic Black, 8% non-Hispanic Other, and 5.4% Hispanic (CDC, 2024). Over the last decade, the number of Black, Hispanic/Latino, and Asian older adults living in nursing homes has increased significantly, while the population of non-Hispanic White residents is declining (Feng et al., 2011; Shippee et al., 2024; Travers et al., 2022). Pervasive racial, ethnic, and class disparities in long-term care in the United States have been observed (Konetzka & Werner, 2009). Due to the influence of systemic racism and related social determinants, individuals from racially and ethnically minoritized groups routinely experience inferior outcomes in healthcare and long-term care compared with non-Hispanic White individuals (Shippee et al., 2024; Travers et al., 2022).

There is no robust nationally representative estimate of the number of nursing home residents who identify as lesbian, gay, bisexual, transgender, queer or questioning, and other (LGBTQ+). Due to the absence of sexual orientation and gender identity questions on the U.S. Census, population estimates rely on alternative data sources and indicate that around 3 million LGBTQ+ adults aged 55 and older currently live in the United States (SAGE, 2025). Less than half of LGBTQ+ individuals disclose their sexual orientation or their sexuality to their primary health care provider (Koch et al., 2023), and it is likely that many individuals residing in LTC settings also do not disclose this information with their healthcare staff. In a systematic review examining both provider and LGBTQ+ individuals’ perspectives on LGBTQ+ issues in long-term care, participants consistently described LTC settings as predominantly heteronormative environments where LGBTQ+ older adults often feel invisible. Many also expressed significant concerns about potential discrimination or negative treatment from LTC staff (Caceres et al., 2020). When seeking long-term care, many encounter significant obstacles, including discrimination, harassment, insensitive or inadequate care, limited LGBTQ+-affirming supports, and the anticipatory stress about concealing their identities (Caceres et al., 2020; Putney et al., 2018). Therefore, providers should recognize that concealment of identity may have been a survival strategy for most of their life, and approach evaluation and treatment with an understanding of minority stress, cumulative disadvantage, and historical trauma. Therapy may require exploring not only current stressors but also the lifelong impact of stigma and trauma.

Prevalence of Mental Health Conditions Among Individuals in LTC Settings

Between 25% and 50% of assisted living facility residents carry a psychiatric diagnosis (Becker, Stiles, & Schonfeld, 2002; Rosenblatt et al., 2004). Among long-term care residents, approximately 75% of residents have one or more mental health diagnosis (Brennan & SooHoo, 2020), with dementia, depression, anxiety disorders, and serious mental illness being the most prevalent (Brennan & SooHoo, 2014, 2020; Lemke & Schaefer, 2010). As many as 82% of nursing home residents report depressive symptoms and as many as 25% have major depression (Seitz et al., 2010). In addition, studies of anxiety disorders in nursing homes estimate a prevalence between 5% and 5.7% (Creighton et al., 2016). A cross-sectional study found that 36% of new nursing home residents had depression and/or anxiety – 25.2% both, 54.3% depression only, and 20.5% anxiety only. Fifteen percent also had co-occurring depression, anxiety, and pain (Ulbricht et al., 2019).

Individuals with various neurocognitive disorders are commonly seen in long-term care (LTC) settings. Research indicates that nearly two-thirds of nursing home residents experience cognitive impairment (Gaugler et al., 2014), and almost half (45.6%) of nursing home residents in 2020 had Alzheimer’s disease or related dementias (CDC, 2025). It has been found that residents with a diagnosis of dementia are more likely to suffer from at least one psychiatric disorder, with anxiety being the most common diagnosis (36.5%), followed by depression (28.6%), and insomnia (14.9%) (Tori et al., 2020).

The Impact of the COVID-19 Pandemic on LTC Residents

The Office of the Inspector General reported that COVID-19 spread was widespread in nursing homes in 2020, with nearly all facilities affected and approximately 1,300 reaching infection rates of 75% or more during the pandemic’s first year (HHS, 2023). Nursing home residents account for less than 0.5% of the U.S. population but accounted for over 21% of reported COVID-19-related deaths (Nursing Home Care Statistics in the U.S, 2025). Since the COVID-19 pandemic, there has been greater recognition of how pandemics and major disasters affect the mental health of long-term care residents.

Before the COVID-19 pandemic, mental health providers faced few barriers when accessing long-term care (LTC) residents who are referred for mental health assessment and treatment, aside from the standard requirement of a physician’s order prior to initiating services. Mental health professionals could enter LTC facilities with relative ease, subject only to routine credentialing procedures. However, in March of 2020, the Centers for Medicare & Medicaid Services ( CMS) directed LTC facilities in all states to restrict nonessential nursing home visits as a means to prevent the virus from spreading. Mental health clinicians who were providing behavioral health services to LTC residents began to encounter difficulties when attempting to see their patients due to lack of clarity about who was considered an essential healthcare worker resulted in many mental health clinicians being refused entry into LTC facilities and disrupted their ability to provide mental health services to their patients (Lind et al. 2023).

The unique characteristics of the pandemic, which was marked by uncertainty, multiple waves of transmission, emerging variants, and both local and global effects, created opportunities for researchers to explore its impact on different population subgroups across a variety of living environments (Lind & Brown, 2025). In long-term care (LTC) settings, mental health providers observed significant declines in residents’ emotional, behavioral, and cognitive functioning during the first seven months of the COVID-19 pandemic, along with increased loneliness and reduced quality of life – particularly in emotional well-being and social connectedness (Lind et al., 2023). Notably during this same period, 71.4% of providers reported being locked out of facilities and temporarily unable to deliver services (Lind et al., 2023).

A Dutch cross-sectional study of long-term care (LTC) residents without severe cognitive impairment, along with their relatives and care staff, revealed heightened loneliness and depressive symptoms, as well as deteriorating mood and behavior, within six to ten weeks of visitor restrictions being implemented (Van der Roest et al., 2020). Subsequent research suggests that residents who already exhibited elevated anxiety and depression before the pandemic experienced greater emotional distress after its onset. Although anxiety was most pronounced early in the pandemic, these symptoms tended to decline over time (Ward et al., 2024; Rose et al., 2023).

Although many long-term care (LTC) residents experience emotional effects during major disasters and pandemics, others demonstrate stability in their emotional and behavioral functioning. Resilience – the capacity to adapt and recover from adversity – is a core aspect of human functioning, and most individuals can regain equilibrium following major crises. Longitudinal research has shown evidence of resilience across the general population, including among vulnerable groups such as older adults at higher risk for severe COVID-19 outcomes (Gambin et al., 2021; Klaiber et al., 2021; Manchia et al., 2022). While older adults may experience periods of psychological distress, studies indicate that they often display strong resilience, especially when supported by meaningful social connections, effective coping mechanisms, and access to technology (Moye, 2022). However, when working with residents in LTC settings, it is important to inquire about whether residents resided in LTC during the pandemic, and if so, how it may have impacted them.

Long-term care residents may differ in their awareness of the emotional effects of a major disaster or pandemic, influenced by their cognitive status, level of insight, and overall awareness. Consequently, providers should be vigilant for a range of emotional and behavioral responses, including distress, agitation, withdrawal, irritability, fear, shock, confusion, decreased appetite, anxiety, sleep disruption, cognitive changes, substance use, depression, stress reactions, behavioral alterations, and suicidal ideation. Emotional impact will not be uniform across residents. Individuals with pre-existing psychiatric disorders, chronic health conditions, or advanced age are especially vulnerable (Vadivel et al., 2021). A history of trauma may further shape or amplify emotional responses to large-scale stressors.

Trauma and Trauma-Informed Care

Individual trauma is defined as an event, series of events, or set of circumstances that an individual experiences as physically or emotionally harmful or life-threatening, leading to lasting negative effects on their mental, physical, social, emotional, or spiritual well-being (Substance Abuse and Mental Health Services Administration , 2014). Even before the COVID-19 pandemic, studies estimated that nearly 90% of people had experienced at least one traumatic event in their lifetime (Kilpatrick et al., 2013). The widespread impact of trauma – and its well-documented associations with both physical and behavioral health conditions such as cardiovascular disease, diabetes, autoimmune disorders, depression, anxiety, and substance use – underscores its significance. As understanding of trauma’s prevalence and long-term effects has expanded, growing numbers of organizations and service systems at state and federal levels have begun implementing trauma-informed approaches designed to better support individuals with trauma histories.

Most LTC facilities receive reimbursement from Medicare and Medicaid and in exchange for this funding, they must comply with federal Requirements of Participation (RoPs) to ensure they provide safe, effective, and high-quality care to residents. CMS revised the RoP for Long-Term Care Facilities in October 2016, issuing a Final Rule rolled out in three phases which was fully implemented by November 28, 2019. Under Phase 2, facilities were required to ensure that residents with mental health conditions – or those showing signs of mental or psychosocial distress – had access to appropriate behavioral health services, unless clinically contraindicated (CMS, 2016). Provisions addressing behavioral health needs of residents with trauma histories were deferred to Phase 3, which took effect shortly before the onset of the COVID-19 pandemic and mandated the provision of trauma-informed care. This mandate (F699 §483.25[m] Trauma-informed care) states that facilities must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care that is in accordance with professional standards of practice and which account for the residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause retraumatization of the resident (Centers for Medicare & Medicaid Services, 2019). The intent of this requirement is to help prevent re-traumatization when a person is triggered to re-experience past trauma, which can occur unintentionally in healthcare environments, including LTC settings. For example, if a female resident has a history of being raped by a male, receiving assistance with showers from a male staff could potentially trigger symptoms that are related to the earlier trauma. Symptoms may present as increased anxiety, panic, hypervigilance, nightmares, and/or avoidance of showers. Anything in one’s surroundings can be a potential trigger to experiencing re-traumatization. This makes it important for mental health providers working in LTC settings to screen for prior trauma history.

Trauma-Informed Care (TIC) is grounded in the core framework developed by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014). At its foundation, TIC acknowledges that trauma is both common and pervasive, particularly among older adults, individuals with chronic illness, and those living in long-term care environments. For behavioral health providers, this means assuming that many residents and staff, whether or not they disclose a trauma history, may carry the psychological, emotional, and physiological consequences of past trauma.

A trauma-informed approach emphasizes understanding how trauma shapes behavior, emotion regulation, and interpersonal functioning. Providers integrate this awareness into every aspect of clinical practice, from assessment and diagnosis to treatment planning, communication style, and interdisciplinary collaboration. The overarching goal is to create clinical interactions and care environments that support safety, empowerment, trust, and choice, thereby reducing the risk of re-traumatization. In practice, TIC encourages mental health professionals to:

• Recognize signs of trauma and trauma-related responses in their patients, staff, and themselves.

• Deliver mental health care in ways that prioritize physical, emotional, and psychological safety.

• Use empathic, nonjudgmental communication that promotes autonomy and shared decision-making.

• Tailor assessment and interventions to each individual’s cognitive, functional, cultural, and psychological needs.

• Collaborate with nursing, medical, and administrative staff to integrate trauma-informed principles facility-wide.

Ultimately, TIC shifts mental health providers from thinking, “What is wrong with this person?” to “What has this person experienced, and how is that experience shaping their current actions and needs?” This perspective helps providers support healing, enhance engagement, and improve clinical outcomes for residents with diverse trauma histories. Table 9 lists the fundamental principles of TIC (SAMHSA, 2014) with description and examples related to LTC.

Table 9. Fundamental Principles of TIC

 

Principle	Description	Key Goals/Examples
1. Safety	Ensures both physical and emotional safety for individuals receiving care.	Create predictable routines, respect privacy, and maintain a calm, welcoming environment.
2. Trustworthiness & Transparency	Builds and maintains trust through honesty, consistency, and openness in actions and communication.	Clearly explain procedures, share decision-making processes, and follow through on commitments.
3. Peer Support	Involves individuals with lived experience of trauma to promote recovery and healing.	Peer mentors share experiences, provide validation, and model resilience.
4. Collaboration & Mutuality	Emphasizes shared power and partnership between providers and clients	Encourage shared decision-making and teamwork; acknowledge clients as experts in their own lives.
5. Empowerment, Voice & Choice	Recognizes and builds on individual strengths; fosters autonomy and self-advocacy.	Offer choices in care, highlight resilience, and support self-determination.
6. Cultural, Historical & Gender Sensitivity	Acknowledges and responds to the impact of cultural, racial, gender, and historical trauma.	Provide culturally competent care, address systemic inequities, and validate diverse identities.

 

Ganzel and colleagues (2025) suggest that direct screening of trauma can be used when individuals have sufficient cognitive capacity and are physically able to participate, meaning they can understand questions and recall information, and are able to communicate. When these abilities are limited or fluctuate, screening should continue but with appropriate adjustments. Ultimately, a person-centered approach is essential, as some residents will benefit from direct screening, while others may require modified or indirect screening.

When directly screening prior trauma history, it is important to gather information in a sensitive and caring manner, as when trust is formed, individuals may be more open to disclosing such personal information. As a provider, it is helpful to let your patients know that you have a set of standard questions to ask to help gather this information, and depending on what is shared, you can work together to identify ways that staff can incorporate person-centered strategies into their care plan to ensure that they feel safe and empowered. Validate their willingness to share the information. It is important to mutually determine what level of information can be shared with other members of the treatment team, with the understanding that the goal is to prevent unintentional triggers and retraumatization in their current environment.

Case Example

Ms. Olson, a 75-year-old female resident in LTC, reports to her nurse that she has been having nightmares for the past several nights. She has been feeling nervous during the day. She has not eaten in the dining room for several days and instead has been staying in her room during mealtimes. She decided not to attend the monthly trip to Walmart this week, which is very unusual for her since it is her opportunity to get needed personal items. Her nurse reports that she appears unusually irritable and impatient, which is out of character for her. Ms. Olson is referred for psychological services because of these emotional and behavioral changes.

Ms. Olson meets with the female psychologist, Dr. Maxwell, and acknowledges that all of the observations made by her nurse are accurate. During the mental status exam, she displays mild cognitive impairment. When screened, she reports mild depressive symptoms and moderate anxiety symptoms. During the clinical interview, Ms. Olson hints at having a “rough childhood.” Dr. Maxwell tells Ms. Olson, “I appreciate you sharing this information with me and letting me know how you are currently feeling. I am wondering if your childhood, or adulthood, has ever consisted of experiencing a traumatic event?” Ms. Olson responded quietly, “How did you know?” Dr. Maxwell responded, “I didn’t know for sure, but I wondered if it could be the case because it is common for symptoms like nightmares, increased vigilance, feeling impatient, and distancing ourselves from others as reactions to reminders of traumatic experiences.”

In further discussing recent events, Ms. Olson discloses that the constant news coverage of the recent mass shooting at Walmart has triggered reminders of her childhood sexual trauma. She stated that “the images of the children shopping to buy school supplies at the time of the shooting are stuck in my mind” and she has been having flashbacks of her own childhood trauma. She didn’t go to Walmart this week because she feared being killed. ​Dr. Maxwell told Ms. Olson that she was grateful that she shared this personal information with her because it has helped her gain insight into her situation and will help guide treatment. She provided psychoeducation on common reactions to trauma and different treatment interventions that could be provided if Ms. Olson chose to engage in further treatment.

Dr. Maxwell also explained how trauma can sometimes be inadvertently triggered in LTC environments given the nature of the setting, such as televisions playing in common areas that may have potentially disturbing news coverage of the recent mass shooting or staff and residents discussing the shooting in the dining room at mealtime. They engaged in a discussion of what information could be shared with the nursing home staff to assist in preventing further re-traumatization. Ms. Olson indicated she was agreeable to Dr. Maxwell sharing with the staff that she would be willing to return to eating in the dining room if the television in the dining room was not set to the news station and that she would prefer to not discuss the recent shooting due to it being emotionally upsetting to her.

Reflection

This is an example of how triggers to trauma symptoms may not always appear to be related to the initial trauma(s). In this case, watching news coverage of a mass shooting was a trigger for Ms. Olson’s childhood sexual trauma. Seeing images of the hurt children triggered her own feelings of feeling unsafe and harmed as a child. Ms. Olson had never shared with nursing staff how she had been feeling or how the news coverage had been impacting her. Given that the television in the dining room always had the evening news playing during dinner, her way of coping was to escape the coverage and eat by herself in her room.

Given that staff had not gained insight into the factors contributing to Ms. Olson’s acute change in emotional functioning, it is important to work with the Interdisciplinary Team (IDT) to help Ms. Olson feel safe and create an environment that does not consist of daily triggers to trauma. Dr. Maxwell did the right thing in praising Ms. Olson for being brave and sharing this information and to also ask permission for what level of detail of information could be shared with the IDT in order to help her. It was decided that details of her childhood trauma were not necessary to discuss with staff, but that they could be told, “Ms. Olson has identified that the news coverage regarding the recent mass shooting is a trigger to her past trauma and it is currently impacting her emotional status. The preference would be to not have the news playing on television in common areas. However, if that is not possible to change, then she has identified a friend who she will eat with in the conference room for the remainder of time that news coverage about the shooting continues. Although it isn’t possible to control what residents and staff will talk about in her presence, she asks that staff do not discuss the recent event directly with her.”

Ms. Olson felt empowered by the plan and during a follow-up session a few days later she reported decreased anxiety and she was starting to re-engage in her prior level of social activities.

Emphasis on Non-pharmacological Interventions in LTC Settings

Non-pharmacological interventions (NPIs) include strategies to manage or improve mental health conditions without the use of medications, such as using psychological interventions (e.g., psychotherapy, stress management, relaxation), physical therapies (e.g., massage, exercise, heat therapy), art therapy, music therapy, nutritional health interventions (e.g., dietary supplements, nutritional therapy) and digital health interventions (e.g., health wearable devices, health coaching programs, virtual reality therapy) (Castellano-Tejedor, 2022). NPIs in any treatment setting can be beneficial by reducing the need for medication, being cost-effective, and usually having no side effects (Ninot, 2021).

In long-term care (LTC) settings, federal regulations require that non-pharmacological interventions (NPIs) be implemented, unless clinically contraindicated, before initiating psychotropic medications (CMS, 2025). Surveyor guidance specifies that when a resident is prescribed a psychotropic medication, the facility must document efforts to use NPIs first and demonstrate that these approaches did not adequately alleviate symptoms causing significant distress. If there is no evidence that appropriate NPIs were attempted or determined to be unsuitable, the use of psychotropic medication is considered unjustified, and the facility may be cited for noncompliance. NPIs encourage LTC staff to look at potential reasons for behaviors, such as pain, fatigue, boredom, loneliness, delirium, trauma triggers, or environmental stressors, rather than solely relying on medication. Facilities must demonstrate they assessed the behavior, identified underlying causes, tried NPIs, and monitored response. Through conducting comprehensive assessments of residents’ emotional and behavioral functioning, mental health providers are uniquely positioned to identify and recommend individualized, patient-centered NPIs as part of collaborative, person-centered treatment planning. Mental health providers help ensure thorough assessment and documentation, reducing regulatory risk.

PLTC Guidelines for Providing Psychological Services in LTC Settings

Although there is strong overlap between the skills of mental health providers working in long-term care (LTC) and those working in other settings, there are unique aspects of the provision of mental health care in LTC settings. To offer guidance to mental health professionals working in LTC facilities, the Psychologists in Long-Term Care (PLTC) organization published Standards for Psychological Services in Long-Term Care Facilities (Lichtenberg et al., 1998). These standards were recently updated (Molinari et al., 2021), with the revised guidelines reflecting a shift from prescriptive “standards” to aspirational “guidelines” to better represent current knowledge, complexity, and diversity in LTC settings. The Psychologists in Long-Term Care (PLTC) Guidelines for Psychological and Behavioral Health Services in Long-Term Care Settings (Molinari et al, 2021) supplement the recommendations of the Pikes Peak model specific to LTC, and highlight aspirations for training, knowledge, and skills needed for psychologists to competently serve the diversity of clients residing in LTC settings. In terms of basic knowledge and skills, the guidelines suggest that education and training include understanding the systems of care, how to work effectively within LTC organizational structures, remaining abreast of relevant state and federal regulations, being familiar with the funding and reimbursement aspects of clinical services provided in LTC, and end-of-life issues (see Appendix II for a summary of these guidelines).

The PLTC Guidelines provide an aspirational framework to guide psychologists (and other mental health providers) in delivering competent, ethical, and person-centered care within nursing homes, assisted living, and related environments. These guidelines emphasize that psychologists working in long-term care must possess specialized knowledge of aging, chronic illness, cognitive impairment, and the unique systemic and regulatory contexts of these settings. They outline the core competencies necessary for effective practice, including appropriate education and training, understanding interdisciplinary care systems, and addressing end-of-life and palliative care issues. Key service activities include conducting comprehensive assessments that consider medical, cognitive, and psychosocial factors; developing individualized, evidence-based treatment plans; and providing interventions tailored to residents’ functional capacities and preferences. Ethical practice is central, highlighting informed consent, confidentiality, privacy, and avoidance of conflicts of interest. The guidelines also stress advocacy for residents’ rights, protection from neglect or abuse, and promotion of psychological well-being within institutional constraints. Overall, the PLTC guidelines underscore the mental health providers’ critical role in supporting emotional health, enhancing quality of life, and fostering collaboration among care teams in the increasingly complex and diverse landscape of long-term care.

Basic psychological service activities in long-term care include understanding the referral process and the factors that influence assessment and treatment planning. Mental health providers must conduct appropriate evaluations, develop individualized treatment plans, and monitor progress over time. Accurate and ethical documentation is essential, along with adherence to professional standards related to informed consent, privacy, and confidentiality. Additionally, providers play a key role in advocating for residents’ mental health needs and collaborating with interdisciplinary teams to ensure comprehensive care.

APA Guidelines for Psychological Practice With Older Adults

The APA Guidelines for Psychological Practice with Older Adults (American Psychological Association, 2024) are designed to help psychologists and other mental health clinicians assess their preparedness to work with older adults and to encourage them to pursue the education, training, and experience necessary to enhance their competence in this specialized area of practice. See Appendix III for a summary of these guidelines.

Mental health providers working in long-term care settings will benefit from referencing these guidelines, as they provide an overview of attitudes, general knowledge about aging, clinical issues, assessment, intervention/consultation, professional issues, and continuing education. A key section of the guidelines emphasizes the need for providers to reflect on their own attitudes, biases, and stereotypes toward older adults. They are encouraged to consider how their beliefs about aging may shape the ways they assess, treat, and set expectations for older clients. Additionally, the guidelines urge providers to build a strong understanding of adult development and the aging process, as well as the diverse factors that influence aging – such as culture, gender, sexual orientation, disability status, and whether an individual lives in a rural or urban environment – along with the biological and health-related changes that occur with age.

The guidelines also address key clinical issues particular to older adults, including cognitive changes, functional decline, comorbid medical and mental health conditions, and the need for tailored assessment and intervention strategies. In conducting assessments, psychologists are advised to use instruments and normative data specifically validated for older adults, rather than relying on tools designed for younger populations without proper modification. When it comes to intervention and service delivery, the guidelines emphasize the importance of being knowledgeable about evidence-based treatments that are effective for older adults, making appropriate adaptations to therapy when necessary – such as accounting for physical, sensory, or cognitive limitations – and taking into consideration the various environments in which older adults receive care, including their homes, outpatient clinics, and long-term care settings.

Mental health providers working with older adults need to collaborate closely with professionals from other disciplines, including medicine, nursing, social work, and rehabilitation, while maintaining an understanding of the care systems in which older adults receive services and adapting to evolving models of service delivery. Ethical considerations are also emphasized, such as balancing autonomy with protection for those with cognitive or physical impairments, addressing consent and confidentiality in diverse settings (e.g., long-term care), and remaining vigilant to ageism and inequities in access to care. The guidelines further stress the importance of ongoing education, supervision, and consultation, as well as practicing within one’s areas of competence or pursuing additional training when needed.

The APA Guidelines can easily be applied to working with older adults in LTC settings. Although “psychologist” is used throughout, the guidelines are generalizable to any mental health professional working with older adults. Below summarizes the APA guidelines with examples of how each guideline could potentially be applied to working with individuals residing in LTC settings. Overall, mental health providers working in LTC settings should recognize which patients’ presenting problems are within their current area of competence and which require additional training or consultation. This is especially important in LTC settings, where complex comorbidities, such as dementia, delirium, behavioral symptoms, and end-of-life issues, are common. General skills and core clinical interventions can often transfer well to those individuals in LTC. Although providers don’t need to be geropsychologists to provide meaningful services, competence still requires understanding the context of aging and recognizing which issues may require specialized skills. Some LTC-relevant problems require specialized skills, such as differential diagnosis of dementia, depression and delirium; understanding polypharmacy and medical comorbidity; managing behavioral and psychological symptoms of dementia (BPSD) and supporting end-of-life issues. Providers should seek training when encountering issues that they don’t feel competent in dealing with. Because many clinicians were not trained in aging during graduate school, mental health providers working with LTC residents must seek supplemental education through continuing education, consultation, and supervision in order to ensure ethical practice.

Summary

The rapidly increasing number of older adults presents a significant opportunity for professionals to expand their practice and meet the growing demand for expertise in geriatric and long-term care settings. Providing services in LTC settings offers a flexible and rewarding environment to providers who desire to work with individuals with a wide range of mental health conditions, life experiences, and rich life stories. However, there is not only an overall shortage of mental health providers, but also a notable lack of clinicians who are trained and experienced in working specifically with older adults. Gaining foundational knowledge in geropsychology is essential for mental health providers because older adults present with unique developmental, medical, cognitive, and psychosocial factors that differ from younger individuals. Understanding normative aging, common late-life mental health conditions, medication effects, sensory and mobility changes, and the impact of chronic illness ensures providers can accurately assess symptoms, avoid misdiagnosis, and tailor interventions appropriately. This knowledge also prepares clinicians to navigate complex care systems, such as long-term care settings, and to collaborate effectively with interdisciplinary teams. Ultimately, geropsychology competence enhances quality of care, promotes autonomy and dignity in later life, and helps meet the growing behavioral health needs of an increasingly older and more diverse population.

Appendices

Appendix I: APA Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change (American Psychological Association, 2021

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General Guidelines: Competence
Guideline 1	Psychologists gain specialized competence in assessment and intervention with older adults.
Guideline 2	Psychologists performing evaluations of dementia are familiar with the prevailing diagnostic nomenclature and specific diagnostic criteria.
General Guidelines: Ethical Considerations
Guideline 3	Psychologists are aware of the special issues surrounding informed consent in older people living with cognitive impairment.
Guideline 4	Psychologists seek and provide appropriate consultation in the course of performing evaluations of dementia and age-related cognitive changes.
Guideline 5	Psychologists are aware of cultural perspectives and of personal and societal biases and engage in nondiscriminatory practice.
Procedural Guidelines: Conducting Evaluations of Dementia and Age-Related Cognitive Change
Guideline 6	Psychologists strive to obtain all appropriate information for conducting an evaluation of dementia and age-related cognitive change, including pertinent medical history and communicating with relevant healthcare providers.
Guideline 7	Psychologists conduct a clinical interview as part of the evaluation.
Guideline 8	Psychologists are aware that standardized psychological and neuropsychological tests are important tools in the assessment of dementia and age-related cognitive change.
Guideline 9	When evaluating for cognitive and behavioral changes in individuals, psychologists attempt to estimate premorbid abilities.
Guideline 10	Psychologists are sensitive to the limitations and sources of variability and error in psychometric performance and to the sources of error in diagnostic decision-making.
Guideline 11	Psychologists make appropriate use of longitudinal data.
Guideline 12	Psychologists recognize that dementia and cognitive impairment are often accompanied by changes in mood, behavior, personality and social relationships, and attend to these in the assessment process.
Guideline 13	Psychologists recognize the importance of assessing family caregiver health and well-being.
Guideline 14	Psychologists recognize that providing constructive feedback, support, and education as well as maintaining a therapeutic alliance are important parts of the evaluation process.
Guideline 15	As part of the evaluation process, psychologists recommend appropriate, empirically-based interventions available to people living with cognitive impairment and their family caregivers.
Guideline 16	Psychologists are aware that full evaluation of possible dementia is an interprofessional, holistic process involving other healthcare providers. Psychologists respect other professional perspectives and approaches. Psychologists communicate fully and refer appropriately to support integration of the full range of information for informing decisions about diagnosis, level of severity, and elements of the treatment plan.

 

Appendix II. Summary of PLTC Guidelines for Providing Psychological Services in Long-Term Settings

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Domain	Subdomain	Key Components
1. Basic Knowledge & Skills	1A. Education & Training	Doctoral/licensed psychology credentials Supervised experience with older adults and LTC settings
	1B. Understanding Systems of Care	Knowledge of LTC organizational structures (skilled nursing, memory care, assisted living) Familiarity with state/federal regulations (e.g., PASRR) Awareness of funding/reimbursement (Medicare, Medicaid, SSI) Interdisciplinary teamwork with staff (nursing, social work, rehab)
	1C. End-of-Life & Specialized Care Issues	Specialized Care Issues Hospice/palliative care knowledge Grief, existential distress, legacy building Integrating cultural/spiritual beliefs about death/aging
2. Basic Psychological Service Activities	2A. Referral, Assessment & Documentation	Understanding referral pathways Using assessment tools (cognitive, functional, behavioral, capacity) Adapting assessment for sensory/medical issues Proper documentation of diagnosis, treatment plan, progress
	2B. Treatment & Evaluation	Developing individualized treatment plans based on assessment Coordinating with interdisciplinary teams, family, care staff Monitoring outcomes and modifying treatment as needed Evidence-based interventions adapted to LTC context
	2C. Ethical, Confidentiality & Advocacy Issues	Informed consent, decision-making capacity, surrogate consent Confidentiality/privacy (HIPAA, facility policies) Conflict of interest (resident vs facility vs payer interests) Advocacy for resident rights, access to services, refusing treatments

 

Appendix III: APA Guidelines for Psychological Practice with Older Adults with Implications for Mental Health Providers Working with Older Adults in LTC settings (adapted from American Psychological Association, 2024)

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Guideline	Application to Long-Term Care
Attitudes
1. Psychologists are encouraged to work with older adults within their scope of competence.	Mental health providers consulting in nursing homes should recognize which patient issues fall within their current competence and which require additional training or consultation. Providers do not need to be geropsychology specialists to provide meaningful services, but competence still requires understanding the patient within the context of aging. Recognize that many core clinical interventions, such as CBT, supportive therapy, and behavioral activation remain effective with older adults in LTC. Familiarity with specialized geropsychology knowledge and specialized skills are needed, such as differential diagnosis of dementia, depression, and delirium. Be cognizant of how historical and cohort factors may impact mental health and coping. Understand “normal” vs. pathological aging processes. Become aware of how medical and functional decline affects psychological well-being. Obtain supplemental continuing education and consultation to ensure ethical practice. Competent practice in LTC settings requires the ability to: Communicate with members of the IDT Understand the LTC regulatory environment Adapt interventions to residents’ functional and cognitive abilities Provide systems-level consultation Awareness of how cognitive changes affect decision-making capacity, risk, and consent.
2. Psychologists are encouraged to recognize ways in which their attitudes and beliefs about aging and about older adults may be relevant to their assessment and treatment of older adults, and to seek consultation or further education about these issues when indicated.	Engage in self-reflection to identify their own attitudes and beliefs about aging and older adults. Ensure emotional concerns are not assumed to be age-related. Recognize the need for further guidance regarding ageism and related issues and seek consultation with colleagues. Become aware of, and challenge, inaccurate stereotypes of older adults that can contribute to negative biases and negatively impact treatment planning. Understand that aging intersects with culture, health, disability, trauma history, gender, and socioeconomic factors to help avoid stereotyped interpretations of behavior or mood. Ensure that assessment measures selected are age-appropriate and valid for use with older adults. Recognize strengths and resilience in patients. Seek to gain specialized clinical exposure and training in working with older adults in LTC settings.
3. Psychologists are encouraged to increase their knowledge, understanding, and skills with respect to working with older adults through training, supervision, consultation, and continuing education, and to apply their expertise in advocacy to support the psychological well-being of older adults.	Pursue continuing education to develop and enhance their competence in providing psychological services to older adults in LTC settings. Possess a general understanding of adult development, the aging process, and the characteristics and needs of the older adult population in LTC. Pursue specialized skills in differential diagnosis. Gain competence in evidence-based interventions and treatments for older adults. Gain experience in working as part of an IDT and effectively collaborate with other medical staff. Gain understanding of diversity within aging (e.g., cultural background, disability, trauma history, Socio-Economic Status,, gender identity) in order to avoid bias and deliver person-centered care. Seek consultation for complex clinical situations that arise.
General Knowledge About Adult Development, Aging, and the Older Adult Population
4. Psychologists strive to gain knowledge about theory and research in aging.	Stay updated with the latest research and theories in geropsychology and long-term care by engaging in continuous education and professional development activities. Understand normal aging vs. pathology to prevent misdiagnosis and improve treatment accuracy. Understand how aging affects test performance and ensure that selected measures are validated in older adults and interpreted appropriately. Effectively collaborate with IDT members. Recognize the psychological impact of chronic illness on mood, cognition, and behavior to help inform accurate clinical interventions. Recognize how age-related changes affect therapy delivery and how modifications can improve their effectiveness. Recognize that nursing home residents come from diverse backgrounds that shape their values, communication styles, family relationships, and expectations for care. Recognize that despite physical decline or chronic illness, many residents continue to have the capacity for growth, adaptation, and resilience.
5. Psychologists strive to be aware of the social and psychological dynamics of the aging process.	Strive to be knowledgeable of issues specific to later life as they relate to LTC settings. Have an understanding of how major late-life transitions, (e.g., moving into a LTC facility, losing a loved one) can impact mental health. Recognize the strengths that older adults possess, the similarities they share with younger individuals, the continuity of their identity over time, and the opportunities to draw on their lifelong skills and adaptations to foster continued psychological growth. Have awareness of how aging affects mobility, sensory functioning, continence, and cognition to help providers understand how these factors may impact patients on a daily basis. Assess social isolation and loneliness while trying to be aware of the diverse configurations of social support in the lives of older adults residing in LTC settings. Identify how meaning, purpose, and wisdom evolve in late life and how these can be utilized as resources and strengths during the therapy process. Strive to understand how developmental history and earlier coping styles influence present behavior and responses. Gain awareness of how psychological dynamics in late life relate to common experiences, such as possible fears about death or dying, identifying unfinished business, and reflecting on life purpose and one’s legacy.
6. Psychologists strive to understand diversity in the aging process, particularly how sociocultural factors such as sex, gender identity, race, ethnicity, socioeconomic status, immigration status, sexual orientation, disability status, religion, spirituality, employment status, and urban/ rural residence may influence the experience and expression of health and of psychological problems in later life.	Gain an understanding of how socioeconomic history impacts coping and mental health in LTC residents. Consider the influence of cohort or generational issues when providing psychological services to older adults in LTC settings. Consider how cultural and racial factors may influence symptom presentation and how residents express depression, grief, pain, or anxiety. Seek to maintain awareness of the diversity in sexual orientation and gender identity and its impact in LTC settings. Consider the pervasive influence of cultural factors associated with race and ethnicity on the experience of aging in LTC settings. Recognize how gender and gender identity shape aging experiences and how older adults residing in LTC settings may have different social roles and expectations, unique vulnerabilities, and/or experiences of stigma or resilience related to gender identity. Strive to provide affirming care to LGBTQ+ older adults in LTC settings by creating a safe therapeutic space, educating staff about inclusive care, and helping residents navigate identity-related stressors. To deliver culturally responsive care, aim to distinguish late-life disparities rooted in cultural factors from those stemming from a history of low income or economic marginalization, which can impact older adults across all cultural backgrounds in LTC settings. Consider the influence of religion and spirituality in the patient’s situation and if these factors have importance, how they can be integrated into treatment. Understand how individuals with a history of disability status or lifelong differences may have different developmental trajectories and support needs than those who acquired disabilities later in life. Recognize the impact of immigration or refugee experiences on current emotional status. Be aware of how intersectionality can impact well-being and that multiple identities can create layered vulnerabilities and influence trust with healthcare providers and the likelihood of reporting symptoms.
7. Psychologists strive to be familiar with current information about biological- and health-related aspects of aging.	Understand how vision decline, hearing loss, slowed processing, and physical fatigue can be common, but also know when symptoms indicate depression, delirium, dementia, or medication effects. Aim to maintain knowledge of common pharmacological treatments used to address mental and physical health conditions in later life. Modify assessments to account for sensory and physical limitations, such as lighting, pacing, use of hearing amplification devices, and the use of repetition of instructions. Gain understanding of how polypharmacy affects cognition and mood (e.g., sedation, agitation, confusion, delirium-like symptoms) in older adults in long-term care settings and collaborate with medical staff to reduce side effects. Recognize the psychological impact of chronic medical conditions and how chronic pain can directly influence mood, cognition, coping, and behavior. Be aware of how physical changes can affect therapy delivery and adjust interventions by considering the need for slower pace or shorter sessions to support increased patient engagement.
Foundations of Geropsychology Practice
8.Psychologists strive to be knowledgeable about psychopathology within the aging population and cognizant of the prevalence and nature of that psychopathology when providing services to older adults.	Expect that mental health symptoms may look different in older adults than in younger adults (e.g., less self-reported sadness and more somatic or cognitive complaints). Recognize subtle symptoms that may indicate early signs of major neurocognitive disorder (dementia), such as difficulty managing multi-step tasks, forgetfulness, and word-finding issues. Recognize that the high prevalence of late-life conditions are common in LTC settings. Be cognizant of the importance of differential diagnosis and recognizing that mental health conditions are often intertwined with medical conditions, medication side effects, and sensory impairment during the diagnostic process. Understand that older adults in LTC settings often have multiple overlapping conditions, and that treatment planning should integrate psychological and medical care. Tailor interventions to patients’ cognitive status by adapting them for changes in attention, memory, and executive functioning. Watch for signs of suicide risk and assess suicidal ideation, intent, and plan, even when depression may not be overtly noted.
9. Psychologists strive to be familiar with current knowledge about normal and disease-mediated cognitive changes in older adults.	Be able to distinguish normal aging memory lapses from early neurocognitive disorder in order to prevent mislabeling normal aging as pathology, or conversely, missing early signs of dementia. Be cognizant of medical conditions that can mimic dementia, such as delirium, and recommend appropriate medical follow-up. Understand how sensory and motor deficits impact cognitive testing and adapt assessments as needed and avoid misinterpretation of results. Psychologists who engage in cognitive testing should be able to recognize cognitive profiles typical of different neurodegenerative diseases (e.g., Lewy body dementia may have attention fluctuations, hallucinations, visuospatial deficits whereas vascular dementia may show a stepwise progression), which helps guide accurate diagnosis and treatment planning. Recognize that acute onset confusion is often a sign of an acute medical condition (e.g., UTI, dehydration, metabolic disturbance) that requires collaboration with nursing and medical staff for immediate follow-up. Understanding the patient’s cognitive status can assist in educating nursing staff on best care approaches to take based on cognitive strengths and limitations. Have an understanding of how mental health conditions can impact concentration and memory in order to avoid misdiagnosis and provide integrated treatment.
10. Psychologists strive to understand and address issues pertaining to the provision of services in the specific settings in which older adults are typically located or encountered.	Be aware that psychological services are provided as the result of a referral from a patient’s physician and must be deemed medically necessary to be reimbursed by payor sources. Understand and adapt to the unique culture and workflow of LTC settings: Learn how care routines (medication times, meals, therapy schedules) affect when and how residents can be seen. Adjust interventions to fit brief windows of availability or the resident’s daily energy patterns. Understand how staffing shortages, turnover, or shift patterns impact care and communication. Stay abreast of LTC-specific Legal, Regulatory, and Ethical Requirements: Understand CMS regulations around: Non-pharmacological interventions Psychotropic medication monitoring Resident rights Trauma-informed care requirements. Manae issues of informed consent when residents have cognitive impairment. Be aware of mandatory reporting requirements for abuse, neglect, or exploitation. Work effectively and collaboratively with IDTs members to ensure coordinated person-centered care. Be aware of documentation requirements that meet CMS guidelines, demonstrate medical necessity standards, and meet surveyor expectations. Offer guidance to staff on individualized, non-pharmacological strategies to address behavioral and psychological symptoms of dementia. Be aware of and manage environmental factors that can impact assessment and treatment, such as adjusting assessments for noise, shared rooms, staff interruptions, and environmental distractions common in LTC. Gain an understanding of system constraints and opportunities, recognizing how resource limitations affect care, advocating for residents while respecting facility policies, and identifying opportunities for environmental or procedural modifications that improve resident well-being.
11. Psychologists strive to be familiar with the application of telehealth practices and policies in assessing and treating older adults across settings and living situations.	Stay abreast with CMS regulations related to billing for telehealth services. Be familiar with licensing and billing requirements based on the state where the provider is located and the state where the patient resides. Be aware that utilizing telehealth can increase access to care in situations such as the patient is located in a rural area where there is a shortage of mental health providers, a crisis situation where immediate assessment via telehealth increases time to treat, and when a patient is quarantined due to contagious medical conditions. Be aware that it is important to collaborate with nursing staff, who are often the ones to serve as facilitators for telehealth sessions. Be cognizant of the importance of adjusting environmental conditions, such as adjusting volume, lighting, or positioning to facilitate effective communication for patients with hearing or vision impairments. Adapt telehealth for residents with cognitive impairment as needed, such as modifying session structure: shorter duration, more visual cues, slower pacing, or integrating caregivers to maintain focus. Try to ensure Privacy and HIPAA Compliance by encouraging staff to close curtains, reduce background noise, position the camera for privacy, and close the door to avoid interruptions.
12. In working with older adults, psychologists are encouraged to understand the importance of interfacing with other disciplines, and to make referrals to other disciplines and/or to work with them in collaborative teams and across a range of sites, as appropriate.	Collaborate closely with nursing staff to better understand behavioral changes and offer non-pharmacological interventions to address emotional and behavioral issues. Work with facility social workers to communicate findings and updates on patients, offer recommendations for person-centered care planning, and coordinating responses when a patient expresses suicidal ideation or other urgent need. Consult with physicians and prescribing providers about psychotropic medications and offer behavioral data to support medication reduction or justify treatment adjustments. Partner with rehab therapists (PT/OT/ST) to coordinate efforts in working with individuals who have emotional or behavioral symptoms that may be negatively impacting their progress in PT/OT/ST (e.g., working with a patient whose fear of falling is impacting his/her participation in PT). Consult with direct care staff (e.g., CNAs) to incorporate their input and observations into person-centered approaches to managing emotional and behavioral concerns. Providers may be asked to participate in IDT care planning meetings, where they can share insights into possible behavioral triggers, observations about cognitive status, risk considerations, and ensuring a psychological perspective can help shape the treatment plan. Providers can act as a bridge between disciplines, translating psychological findings into practical care strategies, encouraging shared problem-solving, and facilitating team communication between various IDT members.
13. Psychologists strive to understand the special ethical and/or legal issues entailed in providing services to older adults.	Anticipate and navigate complex ethical dilemmas by thoughtfully balancing beneficence (protecting the person’s safety and well-being) with respect for autonomy (honoring the individual’s right to make their own decisions whenever possible). Obtain specialized skills before engaging in evaluating an individual’s decision-making capacity. Recognize the signs of elder abuse, neglect, or exploitation and report concerns to appropriate agents (e.g., facility abuse coordinator, Adult Protective Services). Determine when a resident can sign their own consent form or obtain surrogate consent when capacity is diminished or when the individual has a medical Power of Attorney (POA). For those individuals with mild cognitive impairment, providers use simplified explanations, visual aids, or repetition to support informed consent. Maintain and safeguard confidentiality in a shared, high-visibility environment by pulling curtains, finding less noisy or private locations when possible, and by only sharing information with persons authorized to have such information.
14. Psychologists strive to be knowledgeable about public policy, state and federal laws and regulations related to the provision of and reimbursement for psychological services to older adults and the business of practice.	Understand Medicare billing requirements for LTC residents to ensure documentation meets medical necessity standards for reimbursement. Understand federal requirements related to issues that impact behavioral health services, such as non-pharmacological interventions (NPIs), trauma-informed care, and behavioral health service requirements (Phase 3 regulations). Stay abreast of changing healthcare policies such as Medicare reimbursement changes, telehealth expansions or restrictions, state licensing board updates, and new federal behavioral health regulations for LTC to remain compliant. Stay abreast of state-specific mental health laws and state rules governing activities such as mandatory reporting of elder abuse, consent and capacity for treatment, guardianship and advance directives, and telehealth regulations in LTC.
Assessment
15. Psychologists strive to understand the functional capacity of older adults in their own social and physical environment.	Be aware that behavioral symptoms may sometimes be related to functional mismatch between demands and the patient’s abilities. Understand that functional decline may impact judgment, problem-solving, or ability to express preferences. Collaborate with the medical team on interventions that improve both function and psychological well-being. Offer support in adjusting to loss of functional abilities. Providers collaborate with the medical team on interventions that improve both function and psychological well-being.
16. Psychologists strive to be familiar with the theory, research, and practice of various methods of assessment with older adults, and knowledgeable of assessment instruments that are culturally and psychometrically suitable for use with them.	Utilize validated tools suited for nursing home residents and choose instruments that account for sensory loss, low literacy, limited stamina, and/or cultural background. Use behavioral observations to supplement test results, especially when formal testing is limited by cognitive impairment. Consider the importance of gathering collateral information from staff and family members who know baseline functioning and integrate informant reports with testing results to improve diagnostic accuracy. Choose tools validated for diverse populations and avoid over-pathologizing culturally normative behaviors. Avoid using assessment measures with heavy language or education bias in residents with limited formal schooling, non-English backgrounds, or developmental disorders and choose alternatives when available to avoid bias.
17. Psychologists strive to develop skill at conducting and interpreting cognitive and functional ability evaluations with older adults.	Interpret cognitive findings within the context of recent illness, medications, or infection. Select or modify assessment tools for residents with visual impairment, hearing loss, limited education, or low stamina. Consider adjusting evaluations for fatigue, pain, or medical fluctuations by being flexible in splitting assessment across multiple brief sessions if needed, pausing when pain or confusion interferes with performance, or interpreting low scores cautiously when medical conditions may affect cognition. Integrate informant data with formal assessment data when appropriate.
Intervention
18. Psychologists strive to be familiar with the theory, research, and practice of various methods of intervention with older adults, particularly with current research evidence about their efficacy with this age group.	Be aware that older adults in LTC settings respond well to a variety of therapeutic interventions, just as younger adults do Utilize evidence-based treatments supported by research. Adapt therapy for residents with cognitive decline by using repetition, visual cues, or behavioral activation elements instead of complex cognitive restructuring. Adjust interventions for sensory or physical limitations by using larger print materials, visual supports, or verbal-only tasks for residents with vision issues.
19. Psychologists strive to develop skills in adapting psychotherapeutic interventions, including environmental modification, in a manner sensitive to cultural and other individual differences among older adults.	Use more behavioral and sensory-based approaches when individuals cannot engage in abstract insight-oriented work. Modify therapeutic techniques by simplifying language, using visual aids, and repeating key points for residents with cognitive impairment. Take cultural values and backgrounds into account and adapt interventions as needed and integrate cultural values into therapy. Adapt interventions for patients with physical disabilities by allowing therapy to take place in bed, via telehealth, or at bedside when mobility is limited.
Consultation
20. Psychologists strive to recognize and address issues related to the provision of prevention and health promotion services for older adults.	Attempt to identify risk factors for depression (e.g., recent losses). Promote healthy routines for patients to establish regular social contact, engagement in interests, and daily structure to prevent withdrawal and emotional symptoms. Attempt to prevent BPSD by identifying non-pharmacological interventions for staff before behavior escalates by identifying environmental triggers recommending preventive adjustments. Identify and support at-risk individuals, such as LGBTQ+ older adults, individuals without family support, older adults with chronic pain or multiple comorbidities, and individuals with past trauma history. Screen for substance use and identify early signs of alcohol, medication, or substance misuse. Promote sleep hygiene by teaching patients evidence-based strategies to improve sleep to help reduce the risk of agitation, pain, mood symptoms, and cognitive impairment impacted by poor sleep.
21. Psychologists strive to understand issues pertaining to the provision of consultation services in assisting older adults.	Support LTC staff with dementia-related behavioral management strategies. Consult with LTC staff to gain insight into triggers of behavioral changes such as agitation, physical aggression, wandering, and refusing care, in order to offer person-centered strategies. Offer LTC staff non-pharmacological interventions to address resident needs. Consult with LTC administrative staff on pertinent issues such as trauma-informed care and behavioral health requirements for regulatory compliance. Offer psychological insight to IDT members to assist with improving their patients’ wellbeing from a systems perspective.

 

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