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We are an aging society. By the year 2020, one in five Americans will be over the age of 65, compared to a little over one in eight today. The oldest of the old, those over 85, comprise an increasing proportion of the elderly, and present special challenges to health care providers. The clinical care of older adults relies on knowledge of normal aging and the common diseases of old age. This chapter focuses on these aspects of mental health and illness.

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Although chronic and degenerative diseases impact quality of life, most older adults are active, engaged, and pleasure seeking. They remain curious and continue to learn throughout their lives. Temperament (i.e., energy, intensity, reactivity) remains stable through adult life, whereas personality (learned behavior patterns) undergoes refinement and change over time in most healthy adults. Predictable changes in intellect occur in most people as they age. Although judgment, knowledge, and verbal skills increase through the lifespan, mental functions relying on memory and processing speed are adversely affected by aging.

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Successful adaptation to old age is difficult to define and variably expressed. Signs of successful aging include acceptance of change, affectionate relationships with family and friends, and a positive view of one's life story. Another indicator might be the ability to find new sources of self-esteem independent of raising children, career, physical strength, or beauty. Factors that promote successful adaptation are luck (good genes, avoiding injury) and health behaviors that include proper diet, adequate sleep, plenty of physical activity, and stress management. Having enough money for basic needs, and strong kinship and extended family bonds add extra protection from disease and despair, as do spirituality, having friends and confidants, and feeling valued by society. Opportunities to be productive and assist younger generations can provide a sense of connection to one's community and a feeling of completeness.

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Patients and families will often ask for advice on staying engaged and active. Many communities have senior centers, agencies, or programs that organize discussion groups, lectures, hobby groups, book groups, adult education classes, and volunteer activities. Similar programs or groups can be created, even in the smallest communities, by forming book or knitting groups, foster grandparent services, or peer support programs. The local Area Agency on Aging may have information for specific resources and volunteer opportunities in your community.

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Social conditions that contribute to demoralization in old age include highly mobile and rapidly changing communities, youth-oriented aesthetics, the deaths of friends and family members, and forced retirement. Physical conditions that limit function, such as urinary incontinence, chronic pain, gait and mobility problems, and hearing and vision loss also contribute to demoralization. Declining hygiene, poor nutrition, falls, alcohol abuse, social withdrawal, chaotic finances, and denial of severe health problems are clues that an older person is failing at home because of diminishing physical, emotional, or intellectual function. Recognizing these problems can be difficult. Health care practitioners may not detect problems if ...

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