Psychological disorders in older adults

• TYPE OF PSYCHOLOGY: Biological bases of human behavior; Clinical; Counseling; Developmental; Family; Geriatric; Psychopathology; Psychotherapy

In 2020, the population of people in the US older than sixty-five was 16.8 percent, up from 14 percent in 2013 and 11 percent in the late twentieth century. The US Census Bureau predicted this number to exceed 22 percent by 2060. The number of older adults with Alzheimer’s disease is also expected to rise substantially, increasing the overall burden on healthcare systems. The resources that will be spent on the care of older persons make it imperative for those in the medical industry to find effective, efficient, and holistic mechanisms to support the mental and psychological health of older adults. Optimistically, some mental health disorders that older persons face can be prevented or delayed with lifestyle changes.

Introduction

The diagnosis and treatment of mental health problems in older persons is more difficult than that of young people for three reasons. First, there is a greater number of older people than ever before. The result is an increase in cases of certain disorders that previously went unnoticed in the older adult population. Second, the lack of previous data on these disorders makes effectively treating them more difficult. Care must be taken to account for physical differences in the aging body and mind. Diagnostic tools and treatments used for young people may not be appropriate for older patients. Third, many mental health problems in older persons stem from physical problems. Psychologists and caregivers may face a “chicken and egg problem” when diagnosing mental health disorders in older persons. That is, did mental decline begin first, or did physical impairment lead to cognitive impairment? In addition, mental health disorders may change over time symptomatically or may not emerge until one is of advanced age. Care must be taken to properly diagnose and treat the root cause of a mental health disorder in an older person.

Dementia, depression, and anxiety: The big three

Older people may experience the same psychological disorders as younger people. However, there are several conditions that normally do not begin until later in life. The most common of these is dementia, but older persons may also develop depression and/or anxiety.

Alzheimer’s and dementia

Dementia is a common neurocognitive disorder affecting older persons, and it negatively impacts memory, thinking, and reasoning abilities. Simple tasks like driving are affected. Symptoms of dementia include non-cognitive aspects such as agitation, sleep disturbances, elation, and hallucinations.

Alzheimer’s disease is the most common cause of dementia in older persons. It involves the slow and irreversible degeneration of brain tissue due to structural abnormalities or the loss of connections between nerve cells. Initial stages may go undetected, but as the disease progresses, cognitive function gradually declines and worsens to the point of interfering with one’s ability to function normally. Those with this disease ultimately become incapable of caring for themselves. Death typically occurs within several years after initial diagnosis, although this varies widely.

Changes in the blood supply to the brain may also cause dementia. This is known as vascular dementia and is sometimes the result of one or more strokes that block arteries and reduce blood flow to parts of the brain. Vascular dementia can also be the result of chronically damaged brain blood vessels. Much like other blood vessels in the body, brain blood vessels may be damaged from high blood pressure, diabetes, hardening of the arteries, or the wear and tear associated with aging. Older persons sometimes experience dementia-like symptoms without having the disease for other medical reasons, including chronic alcohol use, brain tumors or infections, vitamin deficiency, and thyroid, kidney, or liver disorders.

There is no known cure for Alzheimer’s disease or dementia. Symptoms, however, can be managed with medicines that affect brain function or disease processes. Behavioral and psychological symptoms of the disease can be treated with prescription medications, such as lecanemab (Leqembi), approved in 2023, which targets amyloid plaques in the brain and may help slow cognitive decline in early stages. Diagnosis has also improved with the use of biomarkers, including positron emission tomography (PET) scans and cerebrospinal fluid tests, which help detect early changes in brain chemistry. Additional treatments target disease processes such as amyloid buildup and may help slow cognitive decline in selected patients. These symptoms can also be treated with prescriptions for sleep disturbances, depressed mood, anxiety and restlessness, and hallucinations.

Notably, caregivers also require psychological support and education, as caregiver stress is a significant concern in dementia care.

Delirium

Delirium is a temporary but serious medical emergency similar to dementia that causes patients to be disoriented and inattentive and increases the risk of long-term cognitive decline and mortality. Side effects from certain medications, physical immobility, malnutrition, sleep deprivation, and chronic conditions such as renal disease, stroke, and hearing or vision loss all increase one’s risk of developing delirium. Many can usually be prevented with adequate nutrition, hydration, rest, and by maintaining a patient’s orientation to surroundings. Physical restraints should be avoided if an episode does occur, and the patient should not experience frequent changes in rooms or staff. Sleep is essential in treating patients with delirium; a quiet, low-light setting is appropriate at night. Programs like the Hospital Elder Life Program (HELP) aim to prevent delirium in hospitalized older adults by addressing mobility, sleep, hydration, and sensory input.

Depression

Depression is a mood disorder that causes persistent feelings of sadness and loss of interest in normal daily activities. Depression affects how people feel, think, and behave. Depression in older individuals may manifest in physical symptoms like agitation, health anxiety, and gastrointestinal malfunction. They may also experience confusion, social withdrawal, delusions, and hallucinations. The long-term prognosis for depression in older adults is poor because they tend to have higher relapse rates. Older individuals are also more likely to have concurrent medical problems that exacerbate their conditions, such as cognitive impairment.

Older persons who have had a major surgery, heart attack, stroke, or hearing or vision loss are at increased risk for developing depression. Those who are isolated, have lost loved ones, and lack a supportive social network are also more susceptible to depression. Though historic gender differences exist in depression rates, this difference may be influenced by biological and sociocultural factors like differences in help-seeking behavior. Psychotherapy and mood-improving medications are effective in treating depression in older persons. Once the patient’s mood improves, lifestyle changes should be made to increase social contact and support. Some form of pharmacological maintenance is also in order because of the chronic nature of depression in older adults.

Advances in telehealth therapy and medications like esketamine (Spravato) have significantly improved mental health treatment options for older adults. Online therapeutic programs delivered through apps or online platforms called digital cognitive-behavioral therapy (CBT) are an accessible option for older adults. Interventions include structured exercise, social engagement programs, and integrated medical-psychological care.

Anxiety

Anxiety is a frequent and intense fear and worry about normal situations, sometimes including panic. The feelings of fear are difficult to control and are out of proportion to the actual danger. Generalized anxiety disorder is the most common anxiety disorder in older persons and is characterized by persistent, excessive, and unrealistic worry about everyday things. Like depression, older persons often develop anxiety because of a traumatic event such as developing an illness. Older persons also fear crime, further illness, and financial stress. Limited mobility is an important factor; many older persons have a fear of falling, which can be so severe that they avoid physical activities, leading to further disability. This interferes with daily activities such as shopping and bathing and reduces their overall quality of life. Once an older person has been diagnosed with anxiety, a prescription regimen, sessions with a psychotherapist, or both can be quite effective in treatment. Mindfulness-based therapies, exposure therapy for fear of falling, and behavioral activation strategies have also been shown to be effective. Healthcare providers must be aware of the overlap between anxiety and chronic medical illness, necessitating a holistic approach.

Other mental health disorders

Alcohol and substance abuse. One-third of the money spent on prescription drugs in the US is from older adult patients, who are more likely to be prescribed medications with a high potential for misuse—such as benzodiazepines, opioid analgesics, and sleep aids. It is estimated that a small but significant percentage of older adults misuse prescription drugs, either by taking higher doses than prescribed or using them for nonmedical purposes.

Alcohol use disorder is another important mental health issue affecting older adults. Approximately 10 to 12 percent of adults between fifty and sixty-four, and 5 to 7 percent of those over sixty-five, report engaging in hazardous or excessive alcohol use. These statistics place substance misuse and alcohol-related disorders among the top four mental health challenges facing older adults, after dementia, depression, and anxiety.

Most individuals with a substance use disorder began using substances prior to age sixty-five. These early-onset cases make up the majority of older adults experiencing substance misuse, often with more severe physical and psychiatric complications due to long-term use. Diagnosing late-onset substance use disorders remains difficult, as symptoms may not fit traditional profiles and are frequently misattributed to aging or other medical conditions.

Substance misuse in older adults also increases the risk of co-occurring mental health conditions, such as depression and cognitive impairment. Psychotherapy and/or medications effective in younger populations also benefit older adults, especially when tailored to age-specific needs. Researchers continue exploring geriatric-sensitive treatment models and methods to address polysubstance use, including misuse of cannabis, opioids, and over-the-counter sleep aids.

Bipolar disorder. Bipolar disorder is a chronic condition that involves major shifts in mood, activity, and energy levels. Individuals with bipolar disorder experience alternating episodes of mania or hypomania (elevated or irritable mood, increased energy, and impulsivity) and depression (low mood, fatigue, and loss of interest or pleasure). It is commonly diagnosed in young people and is highly treatable. However, individuals may struggle to carry out their normal daily activities without medical treatment. Some patients do not develop bipolar disorder until late in life. This is far less common but about 10 percent of patients are diagnosed after age fifty. Diagnosing bipolar disorder in older persons is difficult as symptoms may be confused with other possible disorders. Once diagnosed, older adults with bipolar disorder can also benefit from mood-stabilizing drugs. Treatment plans increasingly involve interdisciplinary teams to manage the interaction of psychiatric symptoms with cognitive decline and physical comorbidities. Regular monitoring for side effects, especially in patients taking lithium or anticonvulsants, is essential.

Schizophrenia. Schizophrenia is a serious and chronic condition that affects less than 1 percent of the adult population worldwide. The disorder manifests itself in delusions, auditory hallucinations, confused thinking, erratic behavior, and a pervasively abnormal interpretation of reality. Patients are typically diagnosed in young adulthood although any diagnosis before age forty-five is considered early or normal in onset.

In some cases, it may develop later in life. Individuals who were symptom-free in their youth can be diagnosed between the ages of forty-five and sixty-five (late onset) or with a very late onset schizophrenia-like psychosis (older than sixty-five). Most who are diagnosed with the disorder in young adulthood are males who have otherwise structurally sound brain matter. In contrast, those diagnosed with very late-onset schizophrenia-like psychosis are usually women who have marked brain structure abnormalities and progressive cognitive deterioration. Estrogen may play some protective role in preventing schizophrenia early in life, a protection that disappears after menopause. Atypical antipsychotic medicines are recommended for treatment in older patients. Careful medication management is essential to avoid over-sedation and reduce risks like falls.

Personality disorders. Personality disorders are characterized by rigid, unhealthy, and inaccurate patterns of thinking and behaving. Those with a personality disorder commonly have difficulty relating to people or functioning in normal situations. Generally, extreme symptoms such as aggression decrease with age. However, some traits, such as passive-aggressiveness, health anxiety, and depression, increase with age.

Healthcare workers can more accurately diagnose personality disorders when the more stable psychological factors are taken into greater consideration and when there is correspondingly less emphasis on the more dramatic features of particular disorders. Once diagnosed, some psychotherapeutic treatments focusing on current behaviors and relationships are most effective for older adults. Therapists often use age-adapted therapies and trauma-informed care that are sensitive to generational values, cultural identity, and life course transitions.

Treatment and prevention of behavioral health disorders in older patients

When treating mental health disorders of any type in older adults, extreme caution is advised. Healthcare workers must use diagnostic tools that rule out other medical conditions such as stroke, brain abnormalities, or medicinal side effects. Appropriate medication dosages must be carefully managed when prescribed, as absorption and efficacy can differ for older adults. Furthermore, concurrent medicines may negatively interact with drugs used to treat psychological disorders. Generally speaking, older patients often require much smaller doses because of physical changes associated with aging that affect the metabolism of medicine in the body.

Many mental health disorders persist into young adulthood. However, the big three, dementia, depression, and anxiety, often begin with advanced age and, thus, can largely be prevented. Certain lifestyle changes, such as being mentally active while aging, having frequent social contact, and remaining physically active, can significantly decrease an older person’s likelihood of developing one or more of the common disorders associated with aging. Considering the chicken and egg problem, the number of older persons is increasing at an unprecedented rate, and the bulk of resources spent addressing these issues may be more wisely, and more effectively spent on prevention measures. While aging cannot be stopped, there are actions that communities and individuals can take to help older persons maintain their health and independence.

Many practitioners treating mental health conditions in older adults take a multi-pronged approach, including medical, psychological, and social supports tailored to the individual’s needs. Those with mobility or transportation limitations benefit from telehealth services, which allow them to access care from their homes. Digital tools are also used to support diagnosis, monitor symptoms, and guide treatment decisions in older patients.

Bibliography

Caplan, Zoe. "2020 Census: 1 in 6 People in the United States Were 65 and Over." US Census Bureau, 25 May 2023, www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html. Accessed 28 Mar. 2026.

Cherry, Kendra. "What is Geriatric Psychiatry?" Verywell Mind, 18 Dec. 2025, www.verywellmind.com/psychiatrist-a-career-overview-2795641. Accessed 28 Mar. 2026.

“Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision (DSM-5-TR®).” American Psychiatric Association Publishing, 2022. www.appi.org/Products/dsm. Accessed 28 Mar. 2026.

"Geriatric Psychiatry." American Psychiatric Association, www.psychiatry.org/psychiatrists/practice/professional-interests/geriatric. Accessed 28 Mar. 2026.

“Global Strategy on Digital Health 2020–2025.” World Health Organization, 18 Aug. 2021, www.who.int/publications/i/item/9789240020924. Accessed 28 Mar. 2026.

Jones, Katie F., et al. “Age-Friendly Care for Older Adults with Substance Use Disorder.” The Lancet: Healthy Longevity, vol. 4, no. 10, 2023, pp. e531–32, doi:10.1016/S2666-7568(23)00174-5. Accessed 28 Mar. 2026.

"Mental Health of Older Adults." World Health Organization, 8 Oct. 2025, www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults. Accessed 28 Mar. 2026.

Pathy, M. S. J. Pathy’s Principles and Practice of Geriatric Medicine. 6th ed., Wiley Blackwell, 2022.

“Preventing Alzheimer’s Disease: What Do We Know?” National Institute on Aging, 10 Oct. 2023, www.nia.nih.gov/health/preventing-alzheimers-disease-what-do-we-know. Accessed 28 Mar. 2026.

“Schizophrenia.” World Health Organization, 6 Oct. 2025, www.who.int/news-room/fact-sheets/detail/schizophrenia. Accessed 28 Mar. 2026.

Sinha, Preeti, et al. “Prevalence of Common Mental Disorders in Older Adults: Results from the National Mental Health Survey of India.” Asian Journal of Psychiatry, vol. 55, 2021, p. 102463, doi:10.1016/j.ajp.2020.102463. Accessed 28 Mar. 2026.

Tampi, Rajesh R., et al. Essential Reviews in Geriatric Psychiatry. Springer, 2022.

Thakur, Ujwall, and Anuj R. Varma. “Psychological Problem Diagnosis and Management in the Geriatric Age Group.” Cureus, vol. 15, no. 4, 27 Apr. 2023, p. e38203, doi:10.7759/cureus.38203. Accessed 28 Mar. 2026.

“2025 Alzheimer’s Disease Facts and Figures.” Alzheimer’s Association, 2025, www.alz.org/getmedia/ef8f48f9-ad36-48ea-87f9-b74034635c1e/alzheimers-facts-and-figures.pdf. Accessed 28 Mar. 2026.

“2025 NIH Alzheimer’s Disease and Related Dementias Research Progress Report: Advances and Achievements.” National Institute on Aging, 8 Sept. 2025, www.nia.nih.gov/about/2025-nih-dementia-research-progress-report. Accessed 28 Mar. 2026.