Psychologists need to be alert to the phenomenon of avoiding discussing sexuality with older adult patients because they embrace the idea that older adults are asexual, or because they lack the knowledge of older adult sexuality. Heterosexual women who remarry in later life report higher levels of sexual activity that transition to higher levels of emotional intimacy as compared to prior married life when they were younger. Men in general tend to maintain sexual interest and sexual activity throughout their adult developmental stages, from 35 years of age to the old-old adult developmental stage. Sexual interest remains high throughout these developmental stages, but sexual activity declines in most men as they age. Approximately 16.5" of sexually active older adults have a diagnosis of HIV infection. HIV-infected older adults are heterosexual older adult men and older adult women, gay males, lesbians, and transgendered older adults.

Contemporary psychotherapy addresses behavioral issues of an older adult by focusing on the degree to which an older adult is able to cope positively with the environmental stressors converging on him or her. An environmental geropsychologist focuses on the environment component of Lewin’s equation and develops interventions to change older adults’ interpersonal and intrapersonal experiences with psychosocial stressors with interventions aimed at the environment. The theory of affordances states that the perceptions that older adults have of their physical environments have functional significance for older adults, and shape older adults’ behaviors. The tri-dimensional intervention model states that there is a comprehensive interaction among the cognitive, conative, and affective components in an older adult’s environment. All three components are the targets for intervention by an environmental geropsychologist. The conative component is the aspect of the brain that acts on one’s thoughts and feelings.

A psychologist must confront many prejudices against older adults that are manifested in most people in non-older adult cohorts. Clinical psychologists specializing in geropsychology work with individual older adults; family members of older adults, including spouses/partners, siblings, and adult children; and caregivers when treating the psychological problems experienced by older adults and dealing with issues of caregiving to older adults experiencing mental illness, dementia, and/or psychological reactions to co-occurring medical illnesses. Unfortunately, despite the fact that older adults are affected by the forces of ageism and stigma, and the fact that community psychologists strive to understand and improve social inequalities and to enable empowerment of marginalized people, there is a significant dearth of research in the field of community psychology. There are four types of ageism: personal, institutional, intentional, and unintentional. The majority of older adults have experienced age discrimination and stigmatization at some time after the age of 65.

This chapter talks about psychoactive substances that are commonly misused or abused by older adults. It is important for a psychologist to understand the psychopharmacological dynamics of each substance, how they are administered by an older adult, the symptoms of intoxication and withdrawal, and the psychosocial consequences experienced by the older adult misusing or abusing psychoactive substances. Unlike younger adults, older adults are more likely to avoid illicit substances such as cocaine, heroin, methamphetamine, psychedelics such as lysergic acid diethylamide (LSD) or mescaline, and designer drugs. Historically, the psychoactive substance of choice was alcohol. There are two general types of opioid psychoactive substances: naturally occurring opioids and synthetic opioids. Naturally occurring opioids include opium and its derivatives morphine and codeine, and heroin, which is a chemical manipulation of morphine. Unfortunately, many older adults suffer with chronic pain from cancer, arthritis, or injuries, causing a need for opioid medications.

Older adults experiencing cognitive decline and any of the dementias are suffering in ever increasing numbers. With the aging of the baby-boom generation, the incidence of cognitive decline and dementia will exponentially escalate over the coming years. With this coming tsunami of dementia, older adults experiencing dementia, as well as their family members and caregivers, will need the services of psychologists. Psychologists are needed to help families recognize the importance of end-of-life planning for an older adult when first diagnosed with a dementia. When an older adult understands that he or she has responsibility for and choice in the decision to abuse a psychoactive substance, there is a greater probability of successful treatment and recovery from a substance abuse problem. Psychologists are in a unique position to assess whether older abuse is occurring and, when discovered, to intervene with advocacy initiatives.

A psychologist’s first task when assessing an older adult for dementia is to discriminate between normal cognitive decline, mild cognitive impairment (MCI), and dementia. Teaching an older adult how to increase positive neuroplasticity is a useful intervention that will improve functioning in an older adult experiencing mild cognitive impairment, and will delay the progression of cognitive deterioration in an older adult experiencing dementia. Assessment of deficits in olfactory functioning are potentially useful for a psychologist who is attempting to differentiate between cognitive disturbances of normal aging and mild cognitive impairment that may progress to Alzheimer’s disease. Alzheimer’s disease is a chronic, debilitating disease process that begins with inclusions of abnormal proteins in neurons in the brain, although this stage of the illness does not demonstrate any cognitive impairment in the older adult.

The medical model of psychopathology currently guides psychiatrists and many psychologists who are treating older adults experiencing psychological problems. Use of this model causes contradictions and distortions for the treating clinician and limits the effectiveness of treatment for older adults experiencing psychological problems. There are three areas of concern that illustrate these contradictions and distortions. The first area of concern is the fact that only two classes of psychiatric diagnoses meet the characteristics of a disease. The second area of concern is how the current use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continues a tradition among psychiatry, managed-care companies, and insurance companies that puts pressure on psychiatrists, psychologists, hospitals, and psychiatric rehabilitation facilities to treat in the most cost-effective and short-term manner. The third area of concern is the relationship that has occurred between psychiatry and pharmaceutical marketing forces.

The heightened awareness of coming of death, and the anticipation of dying, results in many older adults experiencing an existential crisis. For some older adults approaching or in the age bracket of 75 to 84 years of age, the expectation of death becomes acute and triggers a need for end-of-life planning, also referred to as advance care planning. Palliative care is considered a good death because it keeps an older adult comfortable, provides counseling, and is a means to control pain that a dying older adult would otherwise experience. There is a significant need for psychologists to provide counseling to older adults experiencing disenfranchised grief because adults experiencing this type of grief suffer from difficulty experiencing their loss when it is not validated by others. Euthanasia is accomplished by an older adult’s request to his or her physician based on the intention of ending pain and suffering when terminally ill.

Psychologists work with micro-level and macro-level orientations. Clinical psychologists with a micro-level orientation focus on individuals, families, and small groups when performing psychotherapy. Community psychologists have a macro-level orientation. The aging population presents many opportunities for psychologists, both those engaged in scholarship and those working clinically with older adults, and for community psychologists addressing issues relating to social structures and organized communities of older adults, economic issues such as poverty and access to medical services, and issues relating to senior housing. Contemporary theory indicates that it is equally important for psychologists working with older adults to focus on the positive aspects of aging when addressing the psychopathological problems older adults are experiencing. Erikson’s stage theory originally had seven stages: basic trust versus basic mistrust; autonomy versus shame and doubt; initiative versus guilt; industry versus inferiority; identity versus role confusion; intimacy versus isolation; and generativity versus stagnation.