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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. © 2013 Shutterfly.com/Yuri Arcurs/ Balounm 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 19 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 Copyright © SLACK Incorporated 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 21 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 –Alzheimer’s Association workgroups 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