Mental Health and
the Elderly
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
Objectives
~ Normal Life-Cycle Tasks
~ Cognitive Capacity With Aging
~ Change, Human Potential, and Creativity
~ Coping With Loss and Bereavement
~ Mood Disorders
~ Alzheimer’s Disease
~ Schizophrenia in Late Life
~ Prevention and Helping the Person Live Well
~ Treatment Overview
~ Overview of Services and Service Delivery Settings
~ Issues Facing Families and Caregivers
Normal Life Cycle Tasks
~ Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function
~ Important aspects of mental health include
~ Stable intellectual functioning
~ Capacity for change
~ Productive engagement with life
Cognitive Decline
~ It is often partly preventable
~ Slowing or some loss of other cognitive functions takes place, most notably in:
~ Information processing
~ Selective attention
~ Problem-solving ability
~ Prevention and early intervention should focus on
~ Encouraging different problem solving tasks (hobbies, puzzles etc.)
~ Maintaining physical activity to improve blood flow
~ Maintaining a good sleep routine (including addressing bladder issues)
Change
~ Capacity to change can occur even in the face of mental illness, adversity, and chronic mental health problems.
~ Older persons display flexibility in behavior and attitudes and the ability to grow intellectually and emotionally.
~ Externally imposed demands upon one’s time may diminish which leaves plenty of time to embark upon new social, psychological, educational, and recreational pathways.
Change
~ Ego Integrity vs. Despair can now be seen in two phases
~ Retirement/liberation
~ feelings of freedom, courage, and confidence are experienced. Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of living
~ Summing up/swan Song (Cohen)
~ tendency to appraise one’s life work, ideas, and discoveries and to share them with family or society. The desire to sum up late in life is driven by varied feelings, such as the desire to complete one’s life work, the desire to give back after receiving much in life, or the fear of time evaporating
Loss and Bereavement
~ Studies on aging reveal that most older people generally do not have a fear or dread of death in the absence of being depressed, encountering serious loss, or having been recently diagnosed with a terminal illness
~ Losses with aging
~ Social status
~ Self-esteem
~ Physical capacities
~ Death of friends and loved ones
~ Other??
Loss and Bereavement
~ Persistent bereavement or serious depression is NOT considered normal.
~ Bereavement is an important and well-established risk factor for depression. At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement. Without treatment, such depressions tend to persist, become chronic, and lead to further disability
Overview of Mental Disorders
~ Older adults are encumbered by many of the same mental disorders as are other adults; however, the prevalence, nature, and course of each disorder may be very different
~ Many older individuals present with somatic complaints which amplify physical symptoms, distracting patients’ and providers’ attention from the underlying depression
~ Many older patients may deny psychological symptoms
~ They experience symptoms of depression and anxiety that do not meet the full criteria for depressive or anxiety disorders
~ High comorbidity with other medical issues
~ Medication side effects
~ Cognitive Decline
Overview of Mental Disorders
~ The large unmet need for treatment of mental disorders reflects
~ Patient barriers (e.g., Underdiagnosis in primary care, tendency to emphasize somatic problems, reluctance to disclose psychological symptoms)
~ Provider barriers (e.G., Lack of awareness of the manifestations of mental disorders, complexity of treatment, and reluctance to inform patients of a diagnosis)
~ Mental health delivery system barriers (e.G., Time pressures, reimbursement policies)
~ Stereotypes about normal aging also can make diagnosis and assessment of mental disorders in late life challenging. For example, many people believe that “senility” is normal and therefore may delay seeking care for relatives with dementing illnesses
Mood Disorders
~ Anxiety disorders are the most prevalent mental health disorders in older adults
~ Benzodiazapines are not recommended for use of more than 6 months in older adults, because of their long-acting compounds
~ Insomnia and sleep disturbance play a large role in the clinical presentation of older depressed patients.
~ Sleep complaints over time in community-residing older people have been found to vary with the intensity of depressive symptoms
~ Problem solving therapy has a 50-60% success rate for depression treatment and gives older adults the tools to cope with stressors
~ Older persons (65 years and above) have the highest suicide rates of any age group. The suicide rate for individuals age 85 and older is about 21 suicides per 100,000
Mood Disorders
~ Minor depression (Depression NOS)
~ Exists in around 8-20% of older adults but is not yet recognized as a disorder in the DSM
~ Minor depression is associated with 51 percent more days lost from work than is major depression
~ Can be an indication of persistent depressive disorder or a response to an identifiable stressor
Dementia and Schizophremia
~ Dementia praecox was an early term given to schizophrenia
~ Schizophrenia can develop in later life
~ Older adults who are having hallucinations or delusions should be screened for schizophrenia as well as alzheimers
Alzheimers
~ There are many causes of cognitive impairment besides Alzheimers.
~ Mild cognitive impairment is not unusual and generally does not meet accepted criteria for Alzheimers.
~ Problems in Alzheimers
~ Memory
~ Language
~ Object recognition
~ Executive functioning
~ Psychosis
~ Agitation
~ Depression
~ Wandering
Substance Abuse
~ Misuse of alcohol and prescription medications appears to be a more common problem among older adults than abuse of illicit drugs
~ Benzodiazepine use represents an area of particular concern for older adults given the frequency with which these medications are prescribed at inappropriately high doses
~ The rate of alcohol use disorders/heavy drinking in older adults is 3-9%
~ Decreased tolerance to alcohol among older individuals may lead to decreased consumption of alcohol with no apparent reduction in intoxication.
Overview of Prevention
~ Primary Prevention
~ Prevent the problem from ever occurring
~ Secondary Prevention
~ Prevent the problem from causing related issues and excess disability (emotional, cognitive, social, physical)
~ Tertiary Prevention
~ Prevent the problem from getting worse
~ Manage an ongoing condition
Helping the Person Live Well
~ Encourage physical activities. Based on results of some studies, exercise or regular physical activity may play a role in living better with the disease. Choose activities you both enjoy.
~ Prepare meals that maintain a balanced diet and are low in fat and high in vegetables.
~ Create a daily routine which promotes quality sleep and engagement with others.
~ Identify situations which may be too stressful for the person with dementia.
~ Work together to find what helps the person relax
~ Focus on the person's strengths and how they can remain as independent as possible
Helping the Person Live Well
~ Help the person with tasks such as
~ Keeping appointments
~ Remembering words or names
~ Recalling familiar places or people
~ Managing money
~ Keeping track of medications
~ Planning or organizing
~ Transportation
~ Learn what to expect in the middle stages of the disease so you can be prepared.
~ Use a calm voice when responding to repeated questions.
~ Respond to the emotion, instead of the specific question; the person may simply need reassurance.
~ Use simple written reminders if the person can still read.
~ If you notice changes, check with the doctor to rule out other physical problems or medication side effects.
Overview of Treatment
~ The special considerations in selecting appropriate medications for older people include
~ Physiological changes due to aging
~ Changes may occur in the absorption, distribution, metabolism, and excretion of psychotropic medications
~ Increased vulnerability to side effects, such as tardive dyskinesia
~ The impact of polypharmacy
~ Interactions with other comorbid disorders
~ Barriers to compliance
Overview of Treatment
~ In general, pharmacological treatment of depression in older people is similar to that in other adults, but the selection of medications is more complex because of side effects and interactions with other medications for concomitant somatic disorders.
~ SSRIs tend to be equally effective as TCA with fewer side effects
~ 60 to 80 percent of older patients with moderate to severe unipolar depression2 can be expected to respond well to antidepressant treatment
Overview of Treatment
~ Cognitive behavioral and problem solving therapy both seem to be effective
~ Cognitive-behavioral therapy is designed to modify thought patterns, improve skills, and alter the emotional states that contribute to the onset, or perpetuation, of mental disorders.
~ Problem-solving therapy postulates through improving problem-solving skills, older patients are able to cope with stressors and thereby experience fewer symptoms of psychopathology
Treatment Settings
~ Landscape for Aging tries to tailor the environment to the needs of the person through a combined focus on health and residential requirements
~ “Long-term care,” has come to refer to a range of services for people with chronic or degenerative illness or disabilities who require support over a prolonged period of time in institutional or community based settings
~ Primary care represents a pivotal setting for the identification and treatment of mental disorders in older people. Many older people prefer to receive mental health treatment in primary care
Treatment Settings
~ Nursing homes, support groups and adult day care are all options to provide caregivers a break
~ Adult day centers, although heterogeneous in orientation, provide a range of services (usually during standard “9 to 5” business hours), including assessment, social, and recreation services, for adults with chronic and serious disabilities
~ National Association of Area Agencies on Aging
~ Selecting a center
Issues for Caregivers (Children/Spouses)
~ Emotions you may experience as a care partner
~ Denial
Short-term denial can provide time to adjust, but staying in denial too long can prevent you and the person with the disease from making important decisions about the future. It also can delay his or her ability to live a quality life.
~ Fear/Stress/Anxiety
Fears about the progression of the disease and the challenges in providing future care can be overwhelming and can prevent you from focusing on the present.
~ Anger/Frustration
Anger towards the diagnosis and a sense of loss of control over the future. Resentment about how your role as a care partner will impact your life.
~ Grief/Depression
Sadness or a sense of loss over your relationship may also lead to feelings of hopelessness. Learn more about symptoms of depression
Summary
~ Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function
~ Decline in cognitive capacity with aging is partly preventable
~ Older persons display flexibility in behavior and attitudes and the ability to grow intellectually and emotionally
~ Losses with aging include Social status, self-esteem, physical capacities, death of friends and loved ones
~ Anxiety disorders are the most prevalent mental health disorders in older adults
~ There are many causes of cognitive impairment besides Alzheimers.
~ Mild cognitive impairment is not unusual and generally does not meet accepted criteria for Alzheimers Schizophrenia in Late Life
Summary
~ Focus on the person's strengths and how they can remain as independent as possible
~ Encourage quality sleep, daily routines and proper nutrition
~ Cognitive behavioral and problem solving therapies have both been found to be effective.
~ Older persons clear medication from their system more slowly and are more susceptible to side effects of many medications.
~ Day treatment/drop in centers are available throughout the country for respite care as well as to facilitate interaction and allow caregivers to work
~ Caregivers often have their own emotional, financial and social needs that need to be addressed when caring for a parent or spouse.