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Addressing issues related to geropsychiatry and the well-being of older adults
Aging Matters
Diagnostic and Statistical Manual
of Mental Disorders-5
Implications for Older Adults and Their Families
ABSTRACT
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5) is targeted for publication in May 2013.
Older adults and their families should be
aware of the potential impact that changes
in this important document may have on
diagnosis and treatment of mental health
concerns. Two specific changes related to a
new category of Neurocognitive Disorders
and a new interpretation of criteria for depression after bereavement are discussed
in this article. Nurses can help older adults
and their families understand the new DSM5 terminology and encourage them to discuss risks, benefits, and likely outcomes of
diagnoses, procedures, and treatments that
may seem unfamiliar.
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A
fter years of work and discussion
about proposed changes, the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),
was approved by the American Psychiatric
Association (APA) on December 1, 2012,
and is targeted for publication in May 2013.
Revision of this essential reference manual
has important implications for diagnosis
and treatment of many different populations. This article focuses on implications
of changes in the DSM-5 for older adults
and their families. Two changes, in particular, have important implications for this
Jeanne M. Sorrell, PhD, RN, FAAN
Journal of Psychosocial Nursing • Vol. 51, No. 3, 2013
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Aging Matters
population: a new category of Neurocognitive Disorders and the removal of
the DSM, fourth edition, text revision
(DSM-IV-TR) (APA, 2000) “bereavement clause” related to depression after
loss of a loved one.
NEUROCOGNITIVE DISORDERS
The Neurocognitive Disorders Work
Group of the APA’s DSM-5 Task Force
was guided by two principles: (a) propose
changes based on advances in scientific
knowledge and current views and clinical
practices; and (b) avoid making changes
for the sake of change, bearing in mind
that all change is disruptive and potentially expensive (Ganguli et al., 2011).
The Task Force has recommended that
disorders previously classified as “Delirium, Dementia, and Amnestic and
Other Cognitive Disorders” are grouped
under the category of “Neurocognitive
Disorders.” Neurocognitive disorders are
considered to be “acquired,” meaning
that the impaired cognition has not been
present since birth or early life. Neurocognitive disorders represent a decline
from a previous level of neurocognitive
function, differentiating these disorders
from developmental disorders (Ganguli
et al., 2011). Evidence for neurocognitive disorders can be based on a report
by a patient, significant other, or both, or
cross-sectional or longitudinal data.
Neurocognitive disorders include mild
and major categories. A mild neurocognitive disorder is characterized by cognitive decline that may affect daily functioning but still allows the person to live
independently. In contrast, the cognitive
deficits with a major neurocognitive disorder are severe enough to interfere with
independence so that the person is likely
to require some assistance with activities of daily living. One concern that has
been expressed in relation to the differentiation between mild and major neurocognitive disorders is the subjective
nature of judging whether the cognitive
deficits are insufficient to interfere with
independence (Siberski, 2012).
Another criterion for diagnosing a
major neurocognitive disorder is sub20
stantial cognitive decline of two or
more standard deviations below appropriate norm, as identified by formal
testing or equivalent clinical evaluation
(Siberski, 2012). The need for cognitive testing to meet this criterion may
add to patient medical costs, as neither
the Mini-Mental State Examination or
the Montreal Cognitive Assessment—
common screening tools used by many
clinicians—provide results in standard
deviations (Siberski, 2012). The formal
testing, however, may help prevent situations that often occur now, in which
even minimal screening for cognitive
deficits is not performed. Research suggests that primary care physicians fail to
diagnose minor to moderate dementia
at least 50% of the time (McPherson &
Schoephoerster, 2012).
One reason why developers of the
DSM-5 believe the new diagnostic category of neurocognitive disorders is
helpful is that if cognitive impairment is
identified early, interventions may be initiated at a stage when they are most helpful (McPherson & Schoephoerster, 2012;
Sperling et al., 2011). A formal diagnosis
may be helpful for a person and family
members who have observed distressing
cognitive changes but did not know the
cause. A diagnosis can also encourage
patients to plan for their future before
cognitive decline begins to interfere with
their judgment and reasoning (McPherson & Schoephoerster, 2012). In addition, with an earlier diagnosis, as with the
mild neurocognitive disorders, therapies
may be started sooner. Research suggests
that some of the medications currently
available for Alzheimer’s disease (AD)
are most beneficial when the patient
exhibits only minor symptoms. Placing
patients on these medications early may
slow the rate of functional decline by 1
year and significantly decrease their likelihood to be admitted to a nursing home;
the medications do not delay mortality, but their use can increase functional
ability (McPherson & Schoephoerster,
2012). Finally, with a DSM-recognized
diagnosis, insurers may be more likely
to reimburse expenses for professional
counseling, which could help individuals
compensate for the memory loss and other deficits they are experiencing (Span,
2013b).
Frequent concerns, however, have
been identified in discussions related
to the new neurocognitive disorders
categorization. Frances (2012) voiced
concern that the everyday forgetting
characteristic of old age will now be
misdiagnosed as a mild neurocognitive disorder, creating a large number
of false-positives for people who are
not specifically at risk for dementia.
One researcher estimated that approximately one fourth of individuals
initially diagnosed with minor cognitive impairment are later found to be
normal (Span, 2013b). Frances (2012)
noted that because no effective treatment exists for this “condition” of
mild neurocognitive disorder, the label provides no benefit but creates
unnecessary anxiety. If a person with
expectable cognitive changes with aging receives a psychiatric label, it may
result in unnecessary treatment with
ineffective prescription drugs and folk
remedies (Frances, 2012).
There are also concerns that objective testing for mild neurocognitive
disorders will be widely ignored in primary care settings, where the diagnosis
for most individuals will take place—
another reason that the new DSM-5
criteria may lead to many false-positives (Siberski, 2012). To address this,
the APA plans to publish a specialized
DSM for primary care physicians that
will help distinguish between normal
cognitive changes of aging and changes
that signify a disease process (Span,
2013b). Considerable research is ongoing to identify biomarkers for the biological brain changes that help predict
dementia, but conclusive findings are
still years away (Span, 2013b). Because
it is not yet possible to determine which
individuals will be affected and which
will not, it appears likely that a large
part of the population diagnosed with
mild cognitive problems will live with
the anxiety that their symptoms may
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Aging Matters
develop to dementia. Thus, it appears
that the DSM-5 will be implemented
among concerns about overdiagnosis
of mild neurocognitive disorders, as
well as unnecessary, expensive, and
ineffective tests and treatments.
GRIEF AND DEPRESSION
Another controversial change in
the DSM-5 concerns grief and depression. It has often been noted that with
deteriorating health in aging and the
loss of friends and loved ones, there
are many reasons for depression in
older adults (Brewster, 2013). Grief is
a universal human experience that has
been seen as a normal and expected
emotional response to loss, with the
majority of people being able to work
through their grief over a course of 2 to
6 months without treatment.
The DSM-IV-TR (APA, 2000) clearly
distinguishes between normal/expected
grief and the more persistent/severe
symptoms of clinical depression that
can occur with bereavement (Brewster,
2013). Under guidelines of the DSM-IVTR, if a person who had just lost a loved
one came to a physician with minor depressive symptoms of sadness, tearfulness,
and insomnia, the physician would be
likely to view these depressive symptoms
as grief related and not diagnose clinical
depression unless the symptoms increased
and lasted longer than 2 months (Friedman, 2012). In the DSM-5, however,
the so-called “bereavement exclusion”
has been removed. This exclusion was a
paragraph that cautioned against diagnosing depression in someone for at least
2 months after loss of a loved one, unless
that patient had severe symptoms such as
suicidal thoughts (Span, 2013a).
Depression has often been underdiagnosed in older adults, but this change in
the revised DSM-5 has led to concerns
that depression may become overdiagnosed. Frances (2012) expressed concern
that normal grief will be diagnosed as
major depressive disorder, thus medicalizing expectable and necessary emotional
reactions to the loss of a loved one and
creating unnecessary anxiety. Without
the bereavement exclusion, an older
adult could be diagnosed with depression after exhibiting symptoms for less
than 1 month after the loss of a spouse.
Although the DSM-5 is expected to include a footnote indicating that sadness
with some mild depressive symptoms in
the face of loss should not necessarily
mentia.” The DSM-5 Task Force decided to replace the term “dementia” with
the new “neurocognitive disorders”
terminology, which will be unfamiliar
to most lay persons. The term dementia is often seen as stigmatizing. Part of
the rationale for avoiding the term is
to avoid focusing on deficit, which is
The Task Force has recommended that disorders
previously classified as “Delirium, Dementia, and
Amnestic and Other Cognitive Disorders” are grouped
under the category of “Neurocognitive Disorders.”
Neurocognitive disorders are considered to be “acquired,”
meaning that the impaired cognition has not been
present since birth or early life.
be viewed as major depression, it opens
the door for clinicians to diagnose major
depression in bereaved individuals after
only 2 weeks of minor depressive symptoms (Friedman, 2012). This could result
in unnecessary labeling of healthy individuals with a psychiatric diagnosis and
encouraging unnecessary treatment with
antidepressant and antipsychotic agents.
IMPLICATIONS FOR NURSES
Nurses caring for older adults with
mental health problems will need education to understand the many changes
in the DSM-5 that will affect interactions with their clients and colleagues
(Flaskerud, 2012). With experts disagreeing on the merits and potential
problems created by changes in the
DSM-5, it will likely be difficult for
older adults and their families to understand how these changes may affect
them personally. Nurses can be helpful
in guiding these individuals through
the potential confusion created by the
new DSM-5 terminology. One big question is likely to relate to the term “de-
Journal of Psychosocial Nursing • Vol. 51, No. 3, 2013
implied by the term dementia. In contrast, the new terminology of neurocognitive disorders focuses on decline from
a previous level of performance, which
is consistent with the definition for an
acquired disorder (Siberski, 2012).
The categories of mild and major
neurocognitive disorders are also likely
to be confusing to lay persons. Under
DSM-5 guidelines, AD can be diagnosed as a mild or major neurocognitive disorder, depending on the extent
of cognitive decline. Adding to the
confusion is that criteria developed
by the Alzheimer’s Association and
the National Institute on Aging use
the term dementia that does not exist
in DSM-5 (Siberski, 2012). Clinicians
who use these criteria will diagnose
dementia, but if using DSM-5 criteria,
they will diagnose mild or major neurocognitive disorder due to AD. The end
result may be confusion for clinicians,
patients, families, and insurers (Siberski, 2012).
Changes in the DSM-5 may affect whether an older adult receives a
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Aging Matters
psychiatric diagnosis—an important
consideration for both clinicians and
clients. One way that nurses can be
helpful is by setting up situations for
shared decision making (Span, 2013b).
If an older adult receives little formal
evaluation for cognitive changes that
result in a diagnosis of neurocognitive
disorder, family members may want to
be cautious and seek a second opinion
before undergoing more tests and treatments. If a label of depression is given a
few weeks after the loss of a loved one,
there may be a need to seek further information and assess options. Following
the DSM-5 blindly may lead to massive
overdiagnosis and harmful overmedication (Friedman, 2012). Nurses can encourage older adults and their families to
discuss options and weigh the risks and
benefits of procedures and treatments to
help them understand likely outcomes.
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th
ed., text rev.). Washington, DC: Author.
Brewster, V. (2013). DSM-5: Bereavement and
depression. Retrieved from http://www.
socialjusticesolutions.org/2013/01/25/dsmv-bereavement-and-depression/
Flaskerud, J.H. (2012). DSM-5: Implications for
mental health nursing education. Issues in
Mental Health Nursing, 33, 568-576. doi:10.3
109/01612840.2012.704132
Frances, A. (2012). DSM5 in distress. The DSM’s
impact on mental health practice and research.
Retrieved from http://www.psychologytoday.
com/blog/dsm5-in-distress/201212/dsm-5is-guide-not-bible-ignore-its-ten-worst-changes
Friedman, R.A. (2012). Grief, depression, and
the DSM-5. New England Journal of Medicine.
Retrieved from http://www.nejm.org/doi/
full/10.1056/NEJMp1201794
Ganguli, M., Blacker, D., Blazer, D.G., Grant,
I., Jeste, D.V., Paulsen, J.S.,…Sachdev, P.S.
(2011). Classification of Neurocognitive Disorders in DSM-5: A work in progress. American
Journal of Geriatric Psychiatry, 19, 205-210.
McPherson, S., & Schoephoerster, G. (2012).
Screening for dementia in a primary care
practice.
Retrieved
from
http://www.
minnesotamedicine.com/PastIssues/
January2012/ScreeningforDementiaina
PrimaryCarePractice.aspx
Siberski, J. (2012). Dementia and DSM-5: Changes, cost, and confusion. Aging Well, 5(6), 12.
Retrieved from http://www.agingwellmag.
com/archive/110612p12.shtml
Span, P. (2013a). Grief over new depression
diagnosis. The New York Times. Retrieved
from
http://newoldage.blogs.nytimes.
com/2013/01/24/grief-over-new-depressiondiagnosis/
Span, P. (2013b). Time to recognize mild cognitive disorder? The New York Times. Retrieved from http://newoldage.blogs.nytimes.
com/2013/01/25/time-to-recognize-mildcognitive-disorder/
Sperling, R.A., Aisen, P.S., Beckett, L.A., Bennett, D.A., Craft, S., Fagan, A.M.,...Phelps,
C.H. (2011). Toward defining the preclinical stages of Alzheimer’s disease: Recommendations from the National Institute on
Aging­
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on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 280-292.
doi:10.1016/j.jalz.2011.03.003
Dr. Sorrell is Senior Nurse Researcher, Cleveland
Clinic Foundation, Cleveland, Ohio.
The author has disclosed no conflicts of interest,
financial or otherwise.
Address correspondence to Jeanne M.
Sorrell, PhD, RN, FAAN, Senior Nurse Scientist,
Cleveland Clinic Foundation, 9500 Euclid
Avenue, Cleveland, OH 44195; e-mail: jsorrell@
gmu.edu.
Posted: March 7, 2013
doi:10.3928/02793695-20130207-01