Psychosocial Rehabilitation and Quality of Life for Older Adults with Serious Mental Illness: Recent Findings and Future Research Directions

Abstract

Purpose of Review

The projected increase of Americans age 65 years and older will have an unprecedented impact on the health care delivery system. As a result, new models to support individuals with serious mental illness (SMI) will become increasingly more important. This selective overview highlights recent reports addressing psychosocial functioning and interventions for older adults with SMI.

Recent Findings

Recently published descriptive studies suggest that poor functional outcomes and lower quality of life among older people with SMI are strongly associated with social isolation, depression, cognitive impairment, and chronic medical illness. Recent research on psychosocial interventions include evaluations of three different models of skills training, a supported employment intervention, and cognitive remediation. This research establishes psychosocial rehabilitation as feasible and potentially effective in improving functioning and quality of life in older adults with SMI.

Summary

Several important directions for future research focused on older adults with SMI are suggested by this overview. They include: individually tailored rehabilitation, interventions that optimize social integration and decrease depressive symptoms, techniques that blend cognitive remediation with vocational rehabilitation, and integration of health promotion with psychosocial rehabilitation.

Introduction

The next two decades will witness an unprecedented increase in the population of older adults with serious mental illness (SMI) [1]. The challenges of treating the growing numbers of older adults with SMI and the associated high costs and service use, will become a major focus of mental health service delivery systems. Compared with the large body of research focusing on psychosocial interventions for younger adults with SMI, the specific needs of older adults have received limited attention. This has important implications as impaired psychosocial functioning is highly associated with increased health care costs, premature institutionalization, increases in hospitalizations, and poor physical and health outcomes in older adults with SMI.

This selective review highlights recent advances in the research literature on psychosocial functioning and interventions for older adults with SMI with respect to the following questions:

1. What conceptual models can be used to describe positive outcomes in psychosocial functioning, and quality of life among older adults with SMI?

2. What factors are associated with greater independent functioning and quality of life in older adults with SMI?

3. What can be done to improve functioning and quality of life in persons with SMI as they age? Specifically, what interventions hold promise for improving functioning, independent living skills, community tenure, and health in older adults with SMI?

This selective review considers literature published in peer-reviewed journals over the last 18 months.

Conceptualizing functioning and quality of life in aging persons with SMI

The field of geriatrics and psychosocial rehabilitation share the common view that maximizing functioning and quality of life are the ultimate measures of a successful intervention. Though difficult to achieve and to measure, these goals supersede more conventional, medically-oriented outcomes such as symptom reduction. As such, identifying the critical variables associated with these outcomes is an important step in designing targeted services and interventions. Several recent reports shed light on the complex question of quality of life and social well-being in aging adults with SMI.

Cohen and colleagues [2**] reviewed 24 studies published over the past 28 years to examine the relationship between aging, severity of symptoms, and quality of life in schizophrenia. This review concluded that positive symptoms decrease with age, negative symptoms and depression are similarly prevalent in younger and older adults, and cognitive impairment tends to increase with age. Surprisingly, no significant associations were found between age and quality of life in schizophrenia. Quality of life in older adults with schizophrenia was only modestly lower than in older adults without a major mental illness. Irrespective of age, lower quality of life in people with schizophrenia was strongly associated with more depression, more positive symptoms, greater cognitive deficits, and more physical disorders. This review identified potentially mutable targets for enhancing rehabilitation outcomes including depressive symptoms, cognition, and physical health.

A second paper, also by Cohen and colleagues [3**], complements the Cohen et al. [2**] review with a theoretical approach to evaluating functional outcomes for older adults with SMI. The authors applied five constructs, including three taken from the field of mental health (remission, recovery, and community integration), and two from the field of aging research (subjective and objective indicators of “successful aging”). The conceptual framework for “successful aging” is drawn from work by Rowe and Kahn [4], reflecting three domains: avoiding disease and disability, retaining good cognitive and physical functioning, and sustaining engagement with life. Comparing a sample of almost 200 older adults with schizophrenia (age 55 and older) to a community comparison group, these five functional indicators were all significantly lower in the schizophrenia group. Community integration was half as likely in the schizophrenia group and only two percent of persons met Rowe & Kahn’s criteria for “successful aging” compared to 19 percent of the comparison group. Examining the same study sample, Bankole and colleagues [5] found that six variables explained 55 percent of the variance in quality of life, including fewer depressive symptoms, lower cognitive functioning, fewer acute life stressors, fewer medication side effects, less financial strain, and better self-rated physical health.

Additional support for targeting depressive symptoms, cognitive functioning, and physical health, so as to enhance quality of life and functioning, comes from a series of recent correlational studies. The critical association of cognition and functioning was demonstrated by Leung and colleagues [6*], who found that neuropsychological status was a better predictor of functional outcome than severity of psychiatric symptoms. The importance of depressive symptoms in older adults with schizophrenia was similarly supported by recent reports on satisfaction with living and social activities [7*], sub-syndromal depression [8*], and suicidal ideation and attempts in middle-aged and older adults with schizophrenia [9*]. Finally, a provocative report by Diwan and colleagues [10**] suggested that depression in older adults with schizophrenia may be intrinsically related to health status. In this study of 198 persons age 55 and older with schizophrenia, clinically significant depression was strongly associated with physical illness (odds ratio 1.6), highlighting the significant relationship between physical illness, disability, and depression in older adults with schizophrenia [10**].

Additional support for extending the focus of rehabilitation to healthcare and health promotion is provided by Vahia and colleagues [11**], who evaluated rates of treatment for common medical problems experienced by older adults with schizophrenia. Older adults with schizophrenia (n=119) received lower rates of treatment than older adults without mental illness (n=57) for hypertension (75% versus 93%), heart disease (38% versus 75%), and for gastrointestinal ulcers (53% versus 100%). There were no differences between the groups on the number of visits to a physician for physical health problems in the prior 12 months. This report suggests that, despite similar numbers of medical visits, the quality of care between the groups is different. Of note, positive symptoms and depression were associated with lower rates of medical care in the schizophrenia group. The authors suggested that medical physicians may lack the appropriate skills and knowledge about how best to communicate with persons with SMI and how to coordinate health care for persons with complex conditions. These factors may result in disparities in health care quality [11**].

In summary, recently published descriptive studies support the need to develop rehabilitative interventions that enhance independent living skills, health, and overall quality of life. Furthermore, specific attention must be given to the critical roles of social integration, mood, cognition, and wellness.

Psychosocial rehabilitation in older adults with serious mental illness: What can be done?

A small, but growing research literature on interventions suggests the potential effectiveness of psychosocial rehabilitation for older adults with SMI. In the following section, we provide an overview of five psychosocial rehabilitation interventions. This includes three skills training models described in a recent review by Pratt and colleagues [12**] and two recent reports, including a vocational rehabilitation intervention [13**] and a cognitive remediation study involving older adults with SMI [14**].

Pratt and colleagues [12**] reviewed psychosocial rehabilitation in older adults with SMI. This review included a description of three skills training interventions that hold promise for improving the health and functioning of older adults with SMI. These interventions include Functional Adaptation Skills Training (FAST), Cognitive Behavioral Social Skills Training (CBSST), and Helping Older People Experience Success (HOPES). The summary below highlights the findings from this literature review and supplements them with additional research that supports the effectiveness of these models.

The first model, Functional Adaptation Skills Training (FAST), provides group sessions aimed at improving community living skills such as managing finances, making/keeping a schedule, taking transportation, communicating, and managing illness. Developed and evaluated by Patterson and colleagues [15,16], this approach uses modeling, rehearsal of skills, and positive reinforcement. A recently published report on a randomized trial (older patients [n = 240] with schizophrenia age 40 and older) found that FAST participants showed significant improvement in social skills and everyday functional skills compared to an attention controlled group. In addition, FAST participants were almost half as likely to use emergency medical services during the active six-month treatment phase of the study, though no difference in service use was found in the subsequent year of follow-up [17*].

Building on these findings, Patterson adapted FAST for Latino adults with schizophrenia and reported favorable outcomes in an initial pilot study [18] of PEDAL (Programa de Entrenamiento para el Desarrollo de Aptitudes para Latinos). The cultural tailoring of PEDAL included: (1) translating the intervention and assessment materials into Spanish, (2) using bicultural/bilingual group facilitators, (3) including culture specific icons and idioms in the handouts for participants, and (4) altering the format and content based on Mexican cultural values. While results from a larger randomized trial are pending, a preliminary report on PEDAL by Mausbach and colleagues [19**] indicated that the tailored intervention was effective in improving functioning and well-being in Latinos with persistent psychotic illness. Overall, the strengths of the FAST and PEDAL programs lie in their positive effects on psychosocial skills, as demonstrated with performance-based measures of function. Additionally, evaluations of PEDAL provide important information on the adaptation of psychosocial rehabilitative approaches for ethnic minority populations.

The second model reviewed is a combined cognitive behavioral and social skills training (CBSST) intervention developed and evaluated by Granholm and colleagues [20]. CBSST provides training in psychiatric illness self-management skills in three modules for a total of 24 weeks. In a randomized trial of CBSST with 76 outpatients with schizophrenia and schizoaffective disorder, the researchers found significant improvements at post-treatment in the CBSST, as compared to the treatment as usual (TAU) group, in social functioning (specifically, involvement in leisure activities), cognitive insight, and performance on a comprehensive module test. No differences were found in symptoms, hospitalizations, or living skills [20]. At one-year follow-up, knowledge scores on the comprehensive module test continued to be higher for participants who received CBSST [21]. The CBSST group also reported better living skills at one-year follow-up than the TAU group [21]. The studies of CBSST demonstrate that the blending of cognitive restructuring techniques with traditional skills training is a uniquely effective method for enhancing living skills in older people with SMI. The lack of effect on symptoms or hospitalizations appears surprising given the focus of the intervention on psychiatric illness self-management.

The third model reviewed combines skills training and a health management intervention. Developed and evaluated by Bartels and colleagues [22], this intervention consists of weekly skills training on living skills and medication self management, together with nurse preventive health care management, to address the significant co-occurrence of medical comorbidity in older adults. In this pre-post pilot study (n = 24), social functioning and living skills improved in conjunction with improvements in access to health care and identification of previously undetected medical problems [22]. Based on this pilot study, a model of integrated psychosocial rehabilitation and healthcare management for older adults with SMI, the Helping Older People Experience Success (HOPES) program, has been developed and described in a recent report by Pratt and colleagues [23*]. Preliminary results from the randomized trial of HOPES indicate that this skills and training preventive healthcare intervention model is effective in improving community living skills [24].

The three models evaluated in these studies include several common components. First, all are group-based, as opposed to individually-focused, which supports the feasibility and practical application of group-based interventions in older adults with SMI. Second, these interventions provide accommodations for individuals with physical or cognitive disabilities and develop skills in incremental steps. Finally, these interventions employ age-appropriate cognitive behavioral principles and skills training techniques to meet the specific needs of older persons. Based on the outcomes reported in these studies, Pratt and colleagues [12**] conclude that social skills training is feasible and is associated with improvement in key dimensions of social functioning and independent community living for older adults with SMI.

Twamley and colleagues [13**] complement these studies of skills training interventions with a study comparing the outcomes of two different work rehabilitation programs for middle-aged and older adults with schizophrenia. The authors analyzed vocational outcomes for participants (n=50) age 45 and older, of which over half were age 50 or older. This study capitalized on numerous randomized trials demonstrating that individualized placement and support (IPS) is superior to conventional vocational rehabilitation and work preparation studies in younger adults. Twamley and colleagues [13**] found that IPS groups were associated with better employment and quality of life outcomes than the comparison group that received conventional vocational rehabilitation support. This important study underscores the concept that competitive employment is not constrained by the boundaries of disability or age. The IPS model does not include volunteer work and meaningful community activities as vocational outcomes. Adapting IPS to include these outcomes may make the model more relevant and applicable to older adults with SMI.

Finally, the use of rehabilitative strategies to improve cognition is addressed in a recent report by McGurk and Mueser [14**]. They compared the outcomes of cognitive remediation in older versus younger adults with SMI. This secondary analysis of data from two randomized studies found that cognitive remediation improved cognitive functioning in the younger group (age 18–44); however, middle-aged and older participants (age 45 and older) showed only minimal improvements in cognitive functioning. The authors speculated that increasing age may be associated with reduced brain plasticity and responsiveness to cognitive rehabilitation, perhaps diminishing the impact of a psychological intervention in older people. At the same time, a significant improvement in negative symptom severity occurred in the older adults, which may suggest a more subtle impact on cognitive functioning in older people [14**]. Given the complexity of these findings, further studies of cognitive remediation in older people are warranted.

Conclusions and Future Directions for Research

This selective overview of recent findings pertaining to rehabilitation for older adults with SMI suggests several areas for development, evaluation, and potential dissemination of rehabilitative interventions for this rapidly growing segment of the population. First, the limited literature on skills training and related rehabilitative interventions largely focuses on group-based interventions. While group-based interventions may have economies of scale, individually-based rehabilitative strategies are also needed that match the specific needs and preferences of the older adult consumer and their targeted rehabilitation goals. Second, studies on quality of life and functioning in older adults with SMI suggest that interventions are needed that optimize social integration, support involvement in meaningful activities, and diminish depressive symptoms. Third, cognitive functioning should be considered as a key variable when assessing critical outcomes for older adults with SMI. Blending cognitive remediation with rehabilitative interventions may hold promise for enhancing the effects of a variety of rehabilitative approaches among older adults. For example, cognitive remediation may improve the success of supported employment interventions for older adults with SMI who are seeking gainful part-time or full-time employment. Finally, there is an urgent need to integrate health promotion, health care, and illness self-management interventions into psychosocial rehabilitative interventions for older adults. Finally, strategies are needed that address the “whole person” as an integrated approach to psychosocial rehabilitation for older adults with SMI, including both the mental and physical health needs [25].