Working with older adults
Cohort effects, medical complexity, and underserved access — therapy works, the field just hasn't shown up consistently.
Who this is
Adults 65+, with high variability — distinguish young-old (65–75), old-old (75–85), and oldest-old (85+) when relevant.
Developmental and contextual frame
Older adults are under-served — fewer therapists trained, more stigma in cohort, more access barriers. Mental health concerns are often masked by medical complexity. Cognitive change matters: distinguish normal aging from MCI from dementia. Loss accumulates — friends, spouse, function, role — and is sometimes treated as 'just life,' when it isn't.
What to assess
- Cognitive screening — MoCA or Mini-Cog when indicated
- Depression — geriatric-specific measures (GDS) reduce false positives from somatic items
- Suicidality — older men have the highest completed suicide rates of any demographic
- Anxiety, often presenting somatically
- Substance use (alcohol especially), often missed
- Medical comorbidities and polypharmacy
- Caregiver stress (when the client is a caregiver)
- Bereavement — likely high
- Functional status — ADLs and IADLs
Modality fit
CBT
Works as well in older adults as in younger ones; pace adjusted.
IPT
Particularly fitting given role transitions in late life.
Problem-solving therapy
Good fit for late-life depression with concrete stressors.
Life-review therapy
Structured reminiscence; reduces depression and increases meaning in older adults.
Brief grief work
For accumulated and ongoing losses.
Common pitfalls
- Assuming older adults can't or won't change
- Ageist countertransference
- Missing depression because somatic symptoms get attributed to medical issues
- Skipping cognitive screening
- Failing to coordinate with primary care and other prescribers
- Pace too fast
What therapists often miss
- Older adults often prefer practical, present-focused work over insight-heavy approaches
- Cohort-specific stigma about mental health and therapy
- Elder abuse — financial, emotional, physical (mandated reporting in many jurisdictions)
- Late-life trauma (medical events, falls, caregiver loss) that triggers prior trauma
- The therapeutic relationship may be one of few intimate connections — handle endings carefully
Resources to share
Area Agency on Aging
Local resource hub for older-adult services.
Eldercare Locator
Federal resource for finding local services.
Caregiver support resources
When the client is a caregiver.
More primers
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Working with LGBTQ+ clients
Affirmative care isn't a modality — it's a stance that runs through everything else.
Working with neurodivergent adults
Late-diagnosed ADHD and autism in adults need affirmative, skills-forward work — not pathologizing.