Aging, Mental Health and Long-term Care by William Cone, Ph.D.

This is a beginning to intermediate level course. After taking this course, mental health professionals will be able to:

Introduction

This course on aging is intended for all clinicians wanting to understand the mental health problems of older Americans. This course also meets the mandatory requirements for license renewal for psychologists, LCSWs, and MFTs in California.

Course Outline

The Importance of a Course on Aging

This country is facing the largest change in demographics in the history of humankind.

People over 55 are now the largest segment of our society, comprising 21 percent of the total population. Those over 65 are now the fastest growing segment of the population. According to the US Census Bureau, the number of Americans aged 65 and older grew from about 3 million in 1900 to over 35 million in 2000. During that period, the ratio of elderly Americans (those over 65) to the total population jumped from one in twenty-five to one in eight.

Thirty five million Americans are now over age sixty–five, and by 2030, that number will reach 85 million. During this time, the number of older:

What is more important is the finding that within the over-65 group, the fastest growing segment is those over 100. In the U.S., the number of people over 100 triples every five years.

First, the baby-boom generation is growing old. During the year after World War II ended, fifteen million soldiers suddenly came home. This rush of returning young men and women resulted in an explosive rise in our population — 76 million children were born, the generation now known as the Baby Boomers. Most Boomers are in their mid-to-late fifties now, and from 1990 and 2020, the population of adults aged 65 to 74 is expected to increase by 74 percent.

Second, people are living longer. Life expectancy has almost doubled, moving from 47.3 years 1900 to 77 years in 2000. During the decades while the Boomers were growing up, breakthroughs in sanitation, nutrition, and medicine led to an unanticipated increase in life expectancy, and an unprecedented increase in the number of elder Americans.

This change was brought about primarily by the establishment of clean drinking water and public sanitation systems, along with the discovery of antibiotics. In 1900, pneumonia, tuberculosis, and diarrhea/enteritis were the three leading causes of death. However, deaths from pneumonia and tuberculosis declined from about 800 per 100,000 in 1900 to only 60 per 100,000 in 1996.

Today, the leading causes of death in America are heart disease, cancer, and stroke. Because of the rapid improvement in medical technology and treatment options, these problems are less life threatening, and life expectancy is predicted to increase even more in the next twenty years.

At present, the fastest growing segment of our population is people over 85, and within this segment, the fastest growing group is people over 100.

Because of this meteoric rise in lifespan, dementing illness has increased significantly. Before the founding of the Alzheimer’s Association in 1980, the disease was considered rare. Today, news about dementia appears in every newspaper, magazine, and television newscast. Thousands of older people alive today will suffer from dementing illness. Most will have emotional and behavioral problems as a result. Currently, very few mental health professionals are knowledgeable about the symptoms, deficits, and treatment of the dementias.

The Need for Geriatric Mental Health Care

In the coming years, thousands of older people will need mental health care. As a healthcare professional, you cannot ignore the impact of this demographic change. As your patients and clients age, they will face new challenges. Many will have multiple medical problems that impact their emotional health and obfuscate accurate diagnoses. The majority will be taking medications that can cause psychological and behavioral problems. Others will have changes in memory and cognition that require that interventions take on a different approach.

Effective intervention and treatment in this population requires a new skill set. And this is why this course has become mandatory.

Age Groups	2000			1990
Age Groups	California	National	percent National	California	National	percent National
Age 15-24	4,832,176	39,183,891	12.3 percent	4,563,942	36,774,327	12.4 percent
Age 25-34	5,229,062	39,891,724	13.1 percent	5,686,371	43,175,932	13.2 percent
Age 35-44	5,485,341	45,148,527	12.1 percent	4,639,321	37,578,903	12.3 percent
Age 45-54	4,331,635	37,677,952	11.5 percent	2,902,569	25,223,086	11.5 percent
Age 55-64	2,614,093	24,274,684	10.8 percent	2,233,226	21,147,923	10.6 percent
Age 65-74	1,887,823	18,390,986	10.3 percent	1,857,221	18,106,558	10.3 percent
Age 75-84	1,282,178	12,361,180	10.4 percent	979,224	10,055,108	9.7 percent
Age 85+	425,657	4,239,587	10.0 percent	299,107	3,080,165	9.7 percent

What is Different About Geriatric Mental Health Care?

Geriatric mental healthcare is based on the premise that older adults have unique psychological needs.

Why Long-term Care?

Part of the mandatory educational requirements is a working knowledge of mental health delivery in a long-term care environment.

This is in part because the majority of people (up to 90 percent) in this setting will be suffering from some form of mental, emotional, or behavioral problems. It is also considered important because the number of people in long-term care facilities is expected to quadruple in the next twenty-five years. Neither the long-term care industry nor the health care professionals who serve their clients are prepared to meet this challenge.

Currently the quality and availability of mental health care leave much to be desired. Mental health problems are routinely ignored, medicated, or tolerated, but seldom treated effectively.

There are a number of reasons for this, one of which is the broad diversity in quality of the facilities. Although many are exemplary in their care and resident-centered focus, others are atrocious. While the best facilities are dedicated to maximizing the quality of life of their residents, the worst facilities focus on the quest to maximize profits and avoid litigation.

It is this stance that has given the news media an abundance of horror stories, and the industry a bad reputation. One administrator told me, “We have a serious marketing problem. We are the only industry where many people would rather be dead than use our services.”

In order for this attitude to change, there must be a fundamental reworking of the delivery of services, and this includes the establishment of high quality mental health care — delivered by you.

What is Long-term Care?

While this might sound like a foolish question, it isn’t. The long-term care industry is still struggling to define itself.

Long-term care services are provided by a range of different entities — including volunteer organizations, government-funded facilities, and private companies.

Technically, the term “long-term care” includes everything from home care and assisted living facilities to residential homes, but the term is most often associated with nursing homes.

Currently there are about 17,000 nursing homes in the United States. About three quarters of long-term care facilities are privately owned, for profit businesses, marketing various levels of care to the infirm elderly. Nonprofit institutions currently provide care for about 28 percent of institutionalized elders, while another 6 percent reside in government-funded facilities. As of 2003, over 14 million people were living in long-term care facilities. Ninety percent of nursing home residents are 65 and above, and 7 in 10 residents are women. Over half of women and about one-third of men over 65 will spend some time in a nursing home.

“Nursing home”… that name. That’s another problem. While the terms “long-term care facility” and “nursing home” are often used interchangeably, there is a difference.

Nursing homes came into being to treat people who were recovering from a serious illness or injury. Once they recovered, they went home.

But today the majority of people living in long-term care facilities will spend the rest of their lives there. Of the people who are admitted to long-term care, only 20 percent will return to their previous homes. The long-term care facility will be their permanent dwelling place — their new homes. This is important because a home should be a sanctuary, a place to feel safe, and a source of nurturance. Despite this, many long-term care facilities bear a closer resemblance to a hospital than a home.

Most people — including mental health professionals — have never set foot in a long-term care facility; this is largely because people avoid them. As of this writing, I have yet to meet a licensed mental health professional whose primary career goal was to work in a nursing home.

Mental Health Services in the Long-term Care Setting

While many community-dwelling elderly people have the same degree of physical disability as those in nursing homes, the decision for placement in a care facility is usually related to the amount of family and social support, and the presence of a psychiatric disorder.

Currently in California and several other states, long-term care facilities house the bulk of the elderly mentally ill. Since the deconstruction of the state mental health system, these people have nowhere to go, and end up in long-term care.

The problem is that many long-term care facilities do not see themselves as a mental hospital, and are not set up to deal with the challenges their residents present. Oftentimes staffs have little or no training in mental health care, and because they are so overwhelmed with the tasks they are given, pay scant attention to the emotional state of the people for which they provide care.

Mental health has always been the bastard child of medicine, but here it is truly an orphan. It is time we changed that, and this is where you fit in.

Mental health problems are rampant in the impaired elderly population. In December of 2003, the reported incidence of mental health problems in long-term care residents was

Source: CMS OSCAR Form 672: F78, F108 - F114 American Health Care Association - Health Services Research and Evaluation

The Impact of Aging on Mental Health

Older adults suffer from the same psychological problems as younger adults. While the proportion of mental health problems is approximately the same for younger adults, older adults are more vulnerable than younger adults to develop psychological problems resulting from factors that impact the quality of life such as stress, ill health, loss, decline in cognitive skills, and changes in living situations.

The Aging Body

Although aging affects everyone, its rate and extent varies from person to person. Changes in childhood and adolescence are stepwise and predictable, but advancing age means increased diversity. In the latter decades of life, people age at very different rates. For this reason, there is no such thing as a typical seventy-year-old.

Aging causes changes in all cells, tissues, and organs, and these changes impair functioning in all of the body’s regulatory and repair body systems.

With age, cells become less able to divide and reproduce. Over time, cells lose their ability to function, or they function abnormally. Cell membranes change, impairing the ability of tissues to get oxygen and nutrients, and to rid the body of carbon dioxide and waste products. There is an accumulation of pigments and fats inside the cells. A fatty brown pigment called lipofuscin collects in many tissues; in the skin, it causes “age spots.” Connective tissue becomes increasingly stiff, which makes organs, blood vessels, and airways less flexible.

Aging organs gradually lose function. Up to a point, this loss goes unnoticed, because people seldom use organs at full capability. This means that in day-to-day life, a person may function normally, but when placed under stress, demands on the system exceed capacity. When demand exceeds capacity, organ failure occurs. Loss of reserve also makes it harder for the body to maintain homeostasis and restore equilibrium. This means prolonged reactions to stress and longer recovery times from illness.

Kidneys lose about 6 percent of capacity every decade after 20. This means reduced capacity to detoxify the body and eliminate waste. This can affect medication dosages also, and toxic buildups are common in this population.

About 20 percent of women and 8 percent of men over 65 will experience urinary incontinence. This has a great impact on their sense of control, and also leads to anxiety, embarrassment, and social isolation.

The most significant changes occur in the heart and lungs. With age, the heart loses elasticity, which reduces capacity. Thickening of the aorta decreases delivery of blood to the muscles. Lungs lose function also. The average 65-year-old today has about 40 percent of the aerobic capacity he had at 30. The combination of decreased heart and lung functions means loss of vital capacity, and impairs the person’s feelings of stamina and well-being. This loss also contributes to the sense of “being old,” and has a great impact on the person’s identity and sense of self. Fortunately, these changes can be minimized by an exercise program. A person’s willingness or reluctance to participate in such a program can tell you a lot about their mood, coping skills, and lust for life.

The Aging Brain

Studies show that brain cells begin to die at an early age. Brain weight actually peaks at 20-25 years and steadily declines thereafter. In healthy people, the brain loses 5 to 10 percent of its weight between the ages of 20 and 90. About 20 to 30 percent of central nervous system cells are lost from age 25 to 80. For some unknown reason, this cell loss is greater in men than it is in women of the same age.

After age 40, the hippocampus — the part of the brain that allows us to store new memories — loses about 5 percent of its cells every ten years. As a result of this cell loss, the average healthy eighty-year-old has about two-thirds of the hippocampal cells that he had when he was born. Although cell loss is significant, there are fortunately, so many cells in these brain areas that the normal loss of cells does not significantly impair brain function.

The greatest loss of neurons occurs in the superior temporal gyrus, a part of the brain that moderates hearing, taste, and smell, and in the anterior central gyrus, which controls movement. The smallest amount of loss occurs is in the posterior central gyrus, which controls peripheral sensation.

As nerve cells are lost, glial cells (cells that support and nourish brain cells) increase in number, size, water content, and weight. Ventricles (the hollow chambers in the brain that contain spinal fluid), increase in size. Myelin (the insulation around the brain cells) thins. Inter- and intracellular deposits of lipofuscin and heavy metals such as aluminum, cadmium, and iron increase. Microtubules (the scaffolding that supports the cell) decrease in number, and the neurofibrillary tangles symptomatic of Alzheimer's, composed of deformed microtubules, proliferate.

Neurotransmitters decrease up to 50 percent in some areas. This occurs especially in the substantia nigra and basal ganglia (areas where dopamine is found) often resulting in Parkinsonian-like symptoms. Dopamine also regulates pleasure and reward, and its loss can cause apathy and disinterest — common symptoms in the elderly, very often mistaken for depression.

Cerebrovascular Integrity

Although the brain undergoes multiple changes with age, research suggests that vascular health is the most potent predictor of overall brain health. In all people, the brain’s blood supply decreases with age. As vessels thicken, they impair the transport of nutrients and oxygen. Capillaries die. Because of this, there is a 20 percent decrease in blood flow from 30 to 70 years of age.

In any part of the brain, thickening and stiffening of the arteries and arterioles will result in disturbances of blood supply, resulting in impaired brain function. The most common causes of this are hypertension, diabetes, cigarette smoking, and hyperlipidemia (elevated levels of fats in the bloodstream that include cholesterol and triglycerides).

Blockage of cerebral arteries by plaques or from emboli (floating bits of fat and cholesterol in the bloodstream) can also block blood flow and cause small strokes (often called infarcts). The most common causes of this are atherosclerosis and cardiac arrhythmias, both found in many older people.

It is important to note that a large proportion of the “older old” (age 80 years and older) in our nation are — or were — long-term smokers, and will be suffering from both vascular and lung problems, both of which impair brain function.

Recent research done in Europe by Alewijn Ott involving more than 9,000 elderly people noted that older smokers lose cognitive abilities five times faster than nonsmokers do. Furthermore, the more a person smoked, the higher the rate of decline they experienced.

Although impaired blood flow is damaging to all parts of the brain, the most vulnerable areas are the basal ganglia and subcortical white matter. In contrast to the cortex, which has a double vascular supply, the subcortical white matter and basal ganglia have but a single, minimally-branching supply. Therefore, any damage in this blood supply means that the basal ganglia or white matter will become ischemic, and cells will experience demyelination, and die. These are parts of the brain responsible for movement, coordination, and volition.

Personality

Although personality appears to remain relatively stable throughout the adult lifespan, changes do occur. For example, in a 2002 study, Helson, Kwan, John, & Jones stated that, in healthy adults, the traits of neuroticism and extroversion decline, while the traits of agreeableness and conscientiousness increase. Another study by Field and Millsap reported that neuroticism decreased until age 69 and remained stable until age 83, while agreeableness increased and extroversion declined until age 83. Elders who score high in neuroticism and low in extroversion have poorer perceived health, and are more likely to suffer from anxiety and depression as result.

In 1964, Neugarten, et. al. conducted a 10-year longitudinal study of aging and personality suggesting that, in healthy elders, change in coping styles, life satisfaction, and goal-oriented behavior remained stable from ages 40-80. However, there was a shift from what they labeled Active Mastery (e.g. risk-taking) to Passive Mastery (greater accommodation, and seeing environments as threatening). With advancing age, subjects reported a greater preoccupation with inner feelings, experiences, and cognitive processes, and avoidance of external influences on belief structures (i.e. more set in their ways).

In 2004, researchers Mroczek & Almeida found that aging resulted in a stronger association between daily stress and negative feelings. The higher a person scored in the trait of neuroticism, the stronger the reaction the person experienced. They concluded that there was a heightened reactivity to stressors in older adulthood, perhaps due to kindling effects, most likely caused by changes in the aging brain (see above).

While the evidence suggests that personality traits are relatively stable, so are personality disorders. This means that older people retain their maladaptive traits as well as their healthy traits. The interface of aging and personality disorders often results in exacerbation of pathologies because of the person’s greater need for help, medical attention, and support. Unfortunately, older people with personality disorders are often described as “grumpy old people” and do not get the help they need.

The presence of a personality disorder is a common reason for referral to a long-term care facility. For this reason, many people in long-term care may be volatile, difficult people who are also struggling with medical problems and cognitive changes. This presents a challenge for staff and administrators, many of whom know nothing about personality disorders and therefore may actually exacerbate problems. There is a great need for mental health professionals to provide intervention and education in this treatment setting.

Family Dynamics

Family therapy is probably the most overlooked resource for the older population. At the time of this writing, we are just beginning to acknowledge the immense need for this type of intervention in dealing with family stress, caregiver burnout, and dealing with very complicated family constellations.

Because of the increase in lifespan, the average adult today will experience triple the amount of years spent with living parents than in 1900. This means more support from parents, but also more responsibility in caring for them. The “sandwich generation” has emerged. Many elders will eventually come to live with their children.

The most common cause of family discord is when a parent becomes too ill to live independently and begins to depend on children for assistance. According to researcher Victor G. Cicirelli at Purdue University, this causes filial anxiety — the anticipation of significant responsibilities often causes friction and conflict between the parent and child. As parents lose the role of power, retaliation and resentment often arise. Old wounds are revisited and old issues reappear.

Friction between siblings is ignited. Old family rivalries and power struggles are reinstated. Adult children of the elderly often become conflicted between control and responsibility. Children argue over who will accept responsibility for the ailing parent. Once the decision is made, the chosen sibling may get constant criticism about the way she is handling things.

Eventually most adult children of elders achieve filial maturity, that is, they have accepted the responsibility of being depended upon by their parents, but in families where the parent-child relationships have been stormy, trouble will brew. Loss of power in which a resented parent reanimates old wounds is a frequent cause of elder abuse.

After rivalries and conflicts have been resolved and caregiving commences, caregiver burnout often occurs. When a caregiver becomes emotionally and physically drained due to the caregiving role, irritability, fatigue, and depression set in. At this point, many caregivers become ambivalent about their role. This may manifest itself as argumentativeness and belligerence, followed by bouts of guilt. Families often become destabilized and volatile without being consciously aware of the source of their discord.

Because of extended life spans and the need for companionship, many elderly people remarry, while others cohabit because of the financial consequences of marriage.

As a result, family constellations become very complex; with multiple marriages come new children, nieces and nephews, stepchildren, and many sets of grandchildren. Boundaries and loyalties are fuzzy and confused, and many conflicts arise.

While working with younger people may not involve family sessions, interactions with family members are an important part of every care plan in this population. At best, the family can be a valuable resource. They can provide historical information and furnish data on what types of care giving have been most successful in the past. They also provide a powerful source of comfort and support for the resident.

But at other times, families may present problems. In many cases, the family members have become accustomed to being the primary caregivers, and are over-involved with the patient. Although they mean well, they may disagree with caregiving, and sometimes actually interfere with treatment.

According to researchers J. Paul Teusnik and Susan Mahler, families of elderly patients with progressive cognitive decline undergo a step-wise process in attempting to cope with the disorder. Teusnik and Mahler feel that families coping with debilitating disease exhibit similar reactions to families coping with death. Because of this, caregivers should provide the families with information and education about this process so that they can see that what they are feeling is normal. With support and guidance, a family can successfully work through its reactions and be able to mourn the loss of their loved one, make the necessary decisions for her care, and reestablish a new family equilibrium.

At first, family members may notice memory and behavioral problems in their loved one, but explain them away by saying that they are just from “stress,” or part of getting old. In spite of the evidence, they insist that there is nothing wrong with their loved one. This reaction is sometimes the result of the family's lack of education about aging, but it is also a wish on the part of family members to deny what they are seeing.

Denial is a way of defending against the pain of loss. In addition, the frequent family fights about how to handle the loved one’s illness may actually be a way for the family to postpone dealing with its grief. In these cases, denial makes any objective assessment, decision-making, and treatment-planning difficult.

Families who exhibit excessive denial must be helped through education and, at times, through outright confrontation in order to recognize the extent of the disability of the family member. Although this may lead to further anger, it is only when denial is overcome that the family will be able to make sound decisions and realistic plans for treatment.

Denial is often followed by intense over-involvement of family members with the patient in an attempt to deal with the illness.

As the deterioration of the afflicted family member becomes more obvious, family members may take over daily tasks and responsibilities in an effort to compensate for the deficits.

At this point, a role reversal takes place. Frequently the family member must almost become a parent to his or her own parent. This can be one of the most difficult adjustments that a family member must face. In addition, he often must assume the patient's former family role, which may include taking over legal and financial responsibilities. This task can be difficult and stressful. Occasionally, family fights break out about who is to take on this responsibility. Sibling rivalry reemerges.

In many cases, a child must take on this role even if the patient’s spouse is still living. Tasks and responsibilities that were done by one spouse for many decades are sometimes incomprehensible to the non-ailing partner. For example, some wives have never written a check or paid a bill, and, in combination with the stress of dealing with illness in their spouse, find the task overwhelming.

When involvement with a parent becomes an obsession, family members sacrifice their personal lives and become consumed with the caregiving task. Even when they recognize that they are in over their heads, they may be reluctant to seek professional help, thinking that to do so is to betray their parent.

In fact, some families raise sons or daughters to believe that they must care for their parents regardless of how disruptive it may be to their own lives. The children feel that to not do so will result in ostracism and ridicule by their family, and their community. This belief often stretches them to the breaking point.

In these cases, the person must be helped to understand what is within his power to do, and what is beyond his limits.

Professional caregivers should be able to recognize the difference between a normal reaction and over-involvement within the family and its culture. Families must be helped to see that their over-involvement is actually a hindrance rather than a help in providing top-quality caregiving.

When doing this, family members should be provided with solid evidence of what problems the over-involvement is causing for the patient, the staff, and for the rest of the family.

Eventually, over-involved family members react in anger, feeling unable to shoulder the tremendous burden of caring for their loved one.

Anger among family members develops for many reasons. In addition to the burden of caring for a disabled spouse or parent, they cannot tolerate the bizarre and socially inappropriate behavior the loved one is exhibiting. Anger also can erupt from the feeling of having been abandoned by a still-living, but now helpless, parent or spouse.

Regardless of its source, this anger is often projected or displaced onto the very people who are trying to help the family deal with their overwhelming sense of helplessness — the caregiving professionals.

Mental health professionals must be able to recognize this, and help the family confront and deal with its anger. When families fail to see that they are projecting their own painful feelings on caregivers, they often accuse staff of neglecting the patient and causing the deterioration that, in reality, naturally occurs with this illness.

Since the normal reaction to being accused of neglect is defensiveness or anger, either of which will further alienate the families, caregivers must be able to handle this anger effectively.

As anger lessens, guilt may become more obvious. Feelings of guilt can be a normal reaction to recognizing the feelings of anger. Guilt may also come from unexpressed-as-unacceptable wishes that the suffering loved one die.

Family members may feel guilty for believing they waited too long before seeking professional help — and by doing so contributed to the suffering. Guilt can also come from the need to make medical and financial decisions that are objected to by the elderly person.

Guilt may also be the reawakening of old feelings — feelings that they were not attentive enough to their parent or spouse in earlier times — or for abrasive and cruel comments from times passed.

Family members often mix their guilt with a dash of failure. They have tried their best to care for their loved one, but the task was more than they could bear. It is vital to keep this in mind when dealing with family members. You cannot truly understand their pain until you have walked in their shoes. In these cases, support groups can be a great resource for families that have been struggling with an ailing elder.

Unfortunately, this guilt sometimes becomes translated into a need to dictate orders to the staff and caregivers. They confuse interference with involvement. One such case involved Jim Stevens and his father.

Mental health professionals can most effectively deal with the family members’ guilt by discovering its cause, and taking corrective steps to alleviate it.

One component of this can be simply to educate the family about the illness itself, thereby providing reassurance that the family has not harmed the patient. More extensive counseling may be needed to help the family make difficult but necessary decisions, some of which may be objected to by the patient.

Acceptance comes only when a family is able to truly understand the disease or disability that is affecting the loved one. Once the family members have worked through the bulk of their anger and guilt, and have recognized that their loved one is no longer the person they once knew, they can accept the loss.

In cases of dementia, acceptance can be especially difficult. This disease's insidious onset and long, slow progress give one false hope that things will remain as they are. In addition, the patient's relatively normal appearance during the early stages of the illness makes the problems seem less serious than they really are.

Here’s an example of these problems in a case described by Teusnik and Mahler:

In other cases, family members have become estranged from the patient, and don’t wish to have any involvement at all. In these cases, unresolved feelings of anger, frustration, helplessness, grief, and fear interfere with healthy family interaction. Once again, family therapy and family support groups can be very useful.

Unfortunately, in some cases, the family members have been not only neglectful, but also abusive. In a survey done in 1988, researchers Pfiffer and Finklehor discovered that between 3 and 4 percent of elders experienced abuse by family members. In the majority of cases, the abuser was the patient’s spouse. They also discovered that only one in fourteen cases was ever reported.

Social support plays an important part in the potential for abuse. Elderly people who are isolated from all but their caregivers are four times as likely to suffer abuse as those who have social support. Men are more likely to be abused than women because elderly men seldom live alone.

Regardless of who they are, how they act, and what they have done, family members must always be treated with respect, deference, and consideration. Like the residents, families must be considered to be customers.

One frequent problem that long-term care residents have is loneliness. Many elders have no families, while those that have families complain that they don’t visit enough. Although this is often true, in some cases these complaints arise because the resident simply doesn’t remember the visits. In these cases, making video recordings of the visits is useful. While a video of a visit is not as gratifying as a real visit, most people enjoy watching the tapes again and again.

Unfortunately, family visits can be a source of trouble. Negative interactions with family can irritate and agitate patients. For this reason, therapists should encourage families to keep the climate of the visit positive. Explain to them that fighting and friction during a visit can cause behavioral problems for several days.

Family visits can also be an opportunity for residents to complain about the facility and the quality of care. Although some of these complaints may be valid, in many cases the person complains of poor care either because they cannot remember many of the things that are done for them, or because they get pleasure out of stirring up trouble.

Because families play such an important role in the mental and physical health of their older loved ones they are an important part of treatment. Therefore, treatment planning includes spending time with the resident’s family.

Get to know them, and learn about their expectations, attitudes, and concerns. They are not only a source of historical information, but also are emotionally involved and impact the life of the person being treated.

Involve the family in the care plan whenever possible. Even minimal participation gives them a feeling of power and participation, and increases treatment compliance a great deal.

Encourage them to join a family support group, and put them in touch with community resources such as the Alzheimer’s Association and the National Family Caregivers Association.

Listen to, acknowledge, and validate the feelings and concerns family members are having. If they are not forthcoming with these feelings, offer information on what kind of feelings are typical and ask them if they are experiencing any of them. For example, you might say, “It’s common for families to feel frightened, depressed, defeated, or guilty about the decision to seek professional help. It would not be unusual for you to be feeling any or all of these things.”

Family members sometimes express their concern and anxiety as anger. When this happens, it is very important that you do not internalize a family member’s anger. This simply means that you don’t take their anger personally. Instead, validate their anger and offer solutions. Be responsive, not reactive. Instead of getting angry, say, “I can hear that you are very upset. I understand. Let’s see what we can do to solve the problem.”

Tell family members about the resident’s current condition. Carefully explain the symptoms and problems that the resident is experiencing. Explaining problems and unusual behaviors helps the family understand and cope with what they are seeing. Explain how the resident’s current condition creates specific needs, and show how these needs can best be met.

Social Dynamics

As mentioned above, adult children tend to minimize the impairments and disabilities of their parents and overestimate their ability to care for them. They are often in denial about the severity of a parent’s illness and have an unrealistic view of their coping skills. Eventually, caregiver burnout takes its toll, and with it comes the realization that a higher level of care is needed.

Although most families make heroic efforts to care for their ailing elderly, many eventually are forced to consider moving the person into a professional care facility.

The decision to admit a parent, a spouse, or any family member to a health care facility is difficult and painful. It is usually made when all other alternatives have been exhausted. It is seldom made without guilt, remorse, hurt, and anger.

The move from home to a retirement home, assisted living, board and care, or skilled nursing facility is a very difficult transition for both resident and family.

To family members, it means the loss of much of what has become familiar. They must adjust to living without the loved one. They must grapple with the reality that they are not equipped to give adequate care. They must lick their wounds and learn their limitations.

To the person entering the professional care facility, it means dealing with multiple losses. She loses her home, her privacy, and her independence. Friends, treasured objects, lifestyle, and much of what she knew are gone forever. This overwhelming sense of multiple losses is usually accompanied by anxiety, depression, and disorientation.

This sense of multiple loss, especially when combined with cognitive and memory problems, usually causes new residents to have extreme difficulty adjusting to their new environment — in short, they don’t know where they are or where their personal belongings have gone, and they get scared.

Although leaving home and entering a care facility is traumatic, relocation from one facility to another also takes its toll on the physical and psychological health of elders. In fact, older people face an elevated mortality risk whenever they are relocated. Studies of the effect of transferring people show that there is an elevated mortality risk — between 1.99 and 3.76 times greater — than those who are not transferred.

In 1992, after years of observing and documenting this problem, health care experts officially named this phenomenon Relocation Stress Syndrome. The United States Administration on Aging calls this problem Transfer Trauma, and notes that relocation is associated with depression, increased irritability, serious illness, and elevated mortality risk.

After a move, the fear and grief that the person experiences are often expressed as anger and agitation. While fear disables a person, anger is empowering. To a person who has lost most of her personal power and position, anger and resistance may be the only way to feel her impact on the world. Therefore it’s not uncommon the see recently relocated people labeled as agitated, combative, and resisting care — when they are actually feeling powerless and helpless.

Understanding the origin of this fear, anger, and resistance allows caregivers to reach beyond the anger and gently touch the pain. A kind word and an understanding attitude can make this difficult transition much more bearable.

The stress of moving to a care facility was carefully examined by Coffman in 1983. He pointed out that it wasn’t the move itself, but the person’s perception of the quality of care and the social support they would receive at the facility that was most traumatic. In other words, it was not the change itself but the emotions that surrounded that change that made the event difficult.

With age, social circles decline. Most institutionalized aged people have no spouse, no close relatives, and the majority of them have no visitors. A new term — elder orphans — has been coined to fit this population. Up to 60 percent of people in long-term care have no family. Because of this, they may have no contact with the outside world. This type of social isolation results in rapid deterioration of physical and mental health.

Another social dynamic that is often overlooked is the impact of cultural differences. For intervention and treatment to be effective, the practitioner must take into account the norms, values, lifestyles, diets, and diseases of various ethnic groups and the impact that they can have on elderly people. Although much work has been done in the field of cross-cultural psychology, little has been done in elderly ethnic populations. Cultural differences affect willingness to seek treatment, compliance with treatment, and the ways that families treat their elder members. For instance, in general, African Americans, Native Americans, and Hispanics place a great deal of importance on self-sufficiency, pride, and independence.

The Impact of Medical Illness on Mental Health

Probably the biggest difference between treating emotional and behavioral problems in younger people and in the elderly is that most elderly people are also suffering from multiple medical problems. Psychological problems in this population are often indicators of physical illness. In fact, more than half of all older psychiatric patients have an undetected physical illness.

Older people who have a previous history of mental illness are more likely to suffer from mental problems in later life. Barring that, medical illness is the strongest predictor of mental illness in the elderly. High medical users are more likely to suffer from depression, anxiety, and adjustment disorders.

Medical illness also predicts cognitive decline. In a 2003 study by Backman, et. Al. looking at how age, social status, education, and substance use affected mental status, only the number of diseases resulting in hospital admission during the follow-up period predicted an accelerated decline in mental status

A troubling finding in geriatric mental health assessment is that almost 80 percent of physical illnesses are missed by psychiatrists during the initial assessment. This happens in part because mental health practitioners are trained to look at symptoms as signs of psychopathology, not medical illness. The other reason for this oversight is that only about 10 percent of psychiatrists specialize in geriatrics.

The reality is that medical problems can cause serious behavioral and emotional disorders, and these factors should always be considered before any diagnosis or behavioral intervention is attempted.

Medical disorders may also present themselves as confusion or functional decline. These things may be mistaken for normal aging, while they are, in fact, masking a serious problem.

It is important to be aware that while there are many people who have medical causes for mental illness, almost everyone has strong emotional responses to physical illness. Disease burden significantly increases levels of stress, anxiety, and depression.

For example, people undergoing dialysis face multiple challenges. First, they must cope with the loss of function of their kidneys. This is a devastating loss, which is often accompanied by a great deal of anxiety, depression, and grieving. Second, dialysis means adopting an entirely new lifestyle — one in which several days a week are devoted to treatment. Third, a majority of people in dialysis feel exhausted after the procedure, and cannot do anything strenuous the rest of the day. Fourth, they must accept strict dietary restrictions to maintain their health.

Dialysis patients also have a high incidence of sleep apnea, which causes cognitive problems and exacerbates fatigue.

Dialysis patients are at risk for thiamine deficiency, which may mimic symptoms of dementia. In rare cases, dialysis can result in a toxic buildup of aluminum in the brain, which results in dementia-like symptoms (sometimes called dialysis dementia). This occurs over time in areas where the water supply contains high levels of aluminum. Although this is a fairly well known phenomenon, it is often overlooked or missed. Untreated, it is often fatal.

The incidence of depression is very high among dialysis patients, and a depression screening should be routine in this population. About one in ten people undergoing dialysis choose to end their lives by discontinuing treatment.

Elderly people often undergo surgery, and although most of these surgeries go well, it is not uncommon to see drastic behavioral changes after their return from the hospital. The trauma of surgery itself always causes a significant amount of stress. The most common problems associated with surgery are:

About 30 percent of older adults will experience irreversible problems with memory and cognition after a major surgery. Problems with memory and thinking after surgery occur because of several factors.

Caloric demand, the amount of energy consumed by the body, often increases as the body tries to heal itself. If nutrition isn’t adequate, the brain is most often the first organ to suffer.

Sometimes tiny clots are thrown during and after the surgery, which may result in minor strokes and, consequently, impaired brain function.

Older people may also fail to metabolize the anesthetic properly. The effects of anesthetic can often linger for weeks after surgery, and can disrupt the person’s ability to function. In addition, being anesthetized for hours may causes anoxia (oxygen starvation) which can lead to diffuse brain damage, causing memory and behavioral problems.

Unfortunately, many elderly residents undergo the loss of a body part, limb, or the loss of the function of a limb. Losing a limb is a traumatic and devastating experience. As well as altering the person’s ability to function normally in the world, the loss changes a person’s body image and sense of self. They no longer feel normal; they no longer feel accepted.

These feelings are made worse by the reactions that others have to the injury. Many people find amputations frightening, and avoid looking at a person with a missing limb. In their efforts to cope with their fear of rejection, the person may become withdrawn or lash out at others, feeling that by rejecting others, they can save themselves from being rejected.

During this time, the person may be difficult to work with — they may be uncooperative, unpleasant, and abusive. It is important to keep this in mind when working with a person who has lost a limb.

It is normal for a person to go through a period of grieving for their missing limb, yet they are often reluctant to discuss their feelings with others. Addressing the issue head-on is often the best way to open the avenue to communication. A statement such as, “Last year I was working with someone who lost her leg. She told me it was a very difficult time for her. I wonder if you might be feeling that way, too.”

Other problems accompany amputations. Blood pressure may be altered. Balance and gait may be affected, and phantom-limb pain may cause discomfort and anxiety. About one-third of women have phantom breast sensations after a mastectomy.

Depression is a common consequence of stroke. This is particularly true if the stroke has resulted in permanent disability. The patient often loses much of his independence, and suffers from the body image difficulties previously discussed.

If the person has lost the ability to speak, things are even worse. Loss of the ability to communicate is a devastating loss, and often results in complete withdrawal.

It is very useful in these cases to get a complete speech and language assessment.

An augmented communication screening is an assessment that determines a person’s ability to use a speech synthesizer (which is often a computer that contains programmed speech). When people are able to use this device their worlds change.

Several years ago, I was called in to see 80-year-old women named Madeline. She had recently become confused, disoriented, and was beginning to show some signs of dementia. In the course of the interview, it was discovered that she was drinking very few fluids. When fluids were increased, the symptoms went away within three days.

Since that time, I have observed that a great many elderly people do not drink enough water. In some cases, this is because they have lost their sense of thirst. But after asking dozens of people why they don’t drink water, the answer I get the most is, “Because it makes me pee.”

And they are right. The decreased fluid intake reduces their need to urinate. Incontinence is often a source of shame and inconvenience, and not drinking reduces the problem. Unfortunately, it also causes fluid and electrolyte imbalance in the brain, and can cause dementia-like symptoms. Very often, correcting incontinence problems eliminates dehydration, and thus eliminates behavioral problems.

Being knocked unconscious can cause a closed head injury. This condition is caused by the bruising or tearing of delicate brain tissue. The brain is a jelly-like substance that is suspended in a bath of spinal fluid. It is protected by rubbery membranes called the meninges. Minor bumps on the head do not usually cause any damage. But getting hit hard enough to cause a loss of consciousness can cause serious injury to the brain’s delicate tissues. Evidence suggests that at any time during the lifespan, losing consciousness for more than one hour triples a person’s risk for dementia.

A concussion is a temporary loss of consciousness occurring after a blow to the head. The impact of the blow causes the semi-liquid brain tissue to slosh about inside the skull, causing it to bruise. Like any bruise, the injured tissue then swells. When the brain becomes bruised and swollen, brain function can be disrupted for weeks after the injury. This can cause loss of memory, and sometimes results in permanent brain damage.

In younger people, most concussions are caused by traffic accidents, but in the elderly they can also occur from falls, or from being hit on the head by any object.

Immediately after a concussion, the victim may experience confusion, memory loss, vomiting, and blurred vision. The longer the person is unconscious, the more severe the symptoms tend to be.

About one-third of the people who experience a concussion will exhibit post concussion syndrome. This condition includes chronic memory loss, dizziness, and changes in behavior that can last over a year. Because most knocks on the head are soon forgotten, the person usually does not connect the symptoms with the accident.

Repeated concussions, such as those experienced by boxers, can cause permanent brain damage, including a condition called punch-drunk syndrome. One study revealed that 87 percent of former boxers showed evidence of brain damage. We also know that a significant number of those suffering from dementia have a history of head injury.

Elderly people often bump their heads and later forget that the incidents happened. In a younger person, these bumps may be unimportant, but the brains of elderly people are sometimes smaller, and slosh about inside the skull more easily. The decreased amount of neurons in the elderly brain makes minor damage more serious. Even small bumps on the head in the elderly, such as a knock on the head from a cabinet door, can cause subdural hematoma (bleeding inside the lining of the brain) Any bump on the head should be checked thoroughly.

As soon as possible after a person has experienced a loss of consciousness, she should see a doctor to rule out skull fracture, brain injury, or subdural hematoma. Subdural bleeding is a serious condition that requires immediate medical attention. Weeks after a head injury, the person may experience headaches, dizziness, changes in behavior, drowsiness, and memory loss.

Dizziness is a common complaint. However, it’s been my experience that most people don’t really mean that they are dizzy. A great many people who complain of dizziness are actually suffering from Parkinsonian difficulties; that is, if they lose their balance, they cannot regain it, and they may fall. Others use the word dizzy to describe muscle weakness or damage that results in unsteadiness, and causes the person to fall or bump into things.

Some people are actually feeling the results of orthostatic hypotension, a sudden drop in blood pressure upon standing. This means that when they stand up too quickly, they feel faint. This drop in blood pressure can be caused by medications or chronic low blood volume. Low blood pressure can also be a sign of internal blood loss, which is a serious condition. Still others are dizzy because of vestibular disorders — malfunctions in the balance apparatus in the ear that result in a feeling that the room is spinning around. Also known as vertigo, this can cause nausea and panic attacks. This can be caused by ear infections or damage to the balance organs themselves.

Nutritional Deficits

The most overlooked and undervalued causes of behavioral and emotional problems are inadequate or poorly balanced nutrition and the nutritional deficits that come with aging.

As people age, they often have deficits in their senses of vision, smell, and taste, decreasing their enjoyment of food. Elderly people also have a tendency to narrow the scope of what they will eat, and therefore may become deficient in certain vitamins and minerals. Often, because of financial difficulties, they consume less protein and increase the consumption of refined carbohydrates, which can destabilize blood sugar. Volatility of blood sugar significantly increases the risk of dementia.

In the long-term care environment, meals often leave something to be desired. Not only is food of poor quality, but dietary preferences are usually ignored. In one facility where I worked, 70 percent of the residents were Hispanic, but despite their complaints, no Mexican food was offered. Being forced to eat food the person does not enjoy, and having no choice in what a person eats, results in non-compliant eating and inadequate nutrition.

Older people may also lose their sense of hunger. It has been found that the biochemical imbalances that cause anorexia in younger people and changes in the natural aging of the brain are very similar. Drug withdrawal and depression may also cause geriatric anorexia.

The consequence of brain changes combined with unhappiness with menu choices often leads to inadequate intake of calories and essential nutrients and a condition known as failure to thrive. In Amsterdam, Dr. Jan Berend Deijen has observed that the level of daily functioning in geriatric nursing home patients is related to both adequate nutrient intake and body weight.

Studies show that about 15 percent of older people require professional intervention for failure to thrive. This condition includes a decline in physical health, weight loss, loss of appetite, and social withdrawal in the absence of any obvious cause. Along with the physical decline, there is often depression, anxiety, and confusion.

Making food more attractive does not have to be expensive. In one study of food intake in long-term care, residents were given a menu for each meal, which gave them two entrée choices. Just doing this increased caloric intake by 25 percent. In another study, adding natural flavoring to meals increased intake and enjoyment of meals significantly. More flavor and aroma compensated for taste and smell deficits that accrue with age.

Sadly, failure to thrive may also be the result of neglect. I have worked with families that literally starved their partners to death. A typical case of neglect was described by Christine Williams-Burgess and Mary Kay Kimball.

Cases of neglect like this often come to light when a patient improves rapidly in the hospital, and again deteriorates when returned home.

Folic acid and B₁₂ levels have been found to be low in a large proportion of residents suffering from various emotional problems, especially depression and anxiety, but deficits also contribute to symptoms of disorientation, depression dementia, and psychosis.

Although B₁₂ deficiency is common in the elderly, measuring levels of B₁₂ in the blood is not always useful. B₁₂ deficiency may not become apparent until long after serum levels have been greatly reduced, and symptoms have begun. In order for this vitamin to be metabolized, it must be transported through the small intestine by a chemical called intrinsic factor. Most people over 60 have significantly low levels of this molecule, and therefore cannot absorb dietary B_12.This means that even if they get enough B₁₂ in their diet, most elders will be deficient. For this reason, B₁₂ deficiency should be assumed to exist in the majority of older people.

The most effective way to get B₁₂into the bodies and brains of the elderly is by injection or by sublingual (under the tongue) tablets, both of which bypass the gastrointestinal system. This should be a routine intervention in all older patients manifesting psychiatric symptoms; however, in the real world it is seldom done. Instead, antipsychotics and antianxiety drugs are administered, which often cause more problems than they cure. (For example, antipsychotic medication appears to increase the incidence of diabetes in this population, and diabetes accelerates dementia. Also, antianxiety medications are the number two cause of falls in the elderly, which are often lethal,)

In studies of elderly people with depression, over 30 percent of subjects were also shown to be deficient in folic acid. In another study, 67 percent of the residents admitted to a geropsychiatric hospital were deficient. As well as depression, folic acid deficiency can also cause chronic forgetfulness, insomnia, anxiety, apathy, and dementia-like symptoms. The combination of B₁₂ and folic acid reduces levels of homocysteine, which reduces risk of cardiovascular disease, and raises levels of SAMe, a natural antidepressant.

Both niacin (vitamin B₃) deficiency and biotin deficiency can exacerbate depression and memory problems, as well as cause emotional instability. Pantothenic acid (vitamin B₅) deficiency can cause restlessness, irritability, and depression.

Thiamin (vitamin B₁) deficiency is very common among alcoholics, and can lead to a condition called Korsakoff's psychosis, which causes profound memory loss, as well as depression, apathy, anxiety, and irritability. B₁ deficiency in the brain results in a condition called metabolic acidosis, which upsets the neurotransmitter balance.

In a few cases, chronic vitamin C deficiency has been shown to cause both hypochondriasis (a preoccupation with bodily symptoms) and depression. In addition, vitamin C has been shown to interact with many central nervous system receptors.

Excessive milk-drinking, taking high amounts of calcium supplements, steroid hormone therapy, and hypothyroidism can all contribute to a condition called hypercalcemia, which may lead to adverse conditions associated with calcium. Symptoms include fatigue, depression, anxiety, panic attacks, headaches, paranoia, memory deficits, and insomnia. High intake of calcium also depletes magnesium.

Diets high in phosphorus (found in lunchmeats, hot dogs, and soft drinks) deplete magnesium. Thyroid hormones can also deplete magnesium. The most common group that experiences magnesium deficits is chronic alcoholics. Depression is related to both alcoholism and alcohol withdrawal, and magnesium sulfate can often reverse this type of depression.

Studies show that magnesium deficiency is found in 25 percent of people with eating disorders such as obesity and anorexia. Low magnesium levels have been linked to many problems including loss of appetite, muscle weakness, and cramps in the feet and legs. Psychological symptoms include agitation, anxiety, depression, hallucinations, insomnia, and confusion. The recommended daily allowance for magnesium is 200 to 300 mg per day.

Although the exact mechanism is not known, excess potassium has long been associated with depression. This is often seen in uremic patients. A deficiency of potassium is also associated with depression and is most commonly seen in patients with frequent vomiting or prolonged diarrhea, and in people receiving diuretics or steroids.

Elderly people with heart problems, particularly those in cardiac failure, sometimes eliminate sodium from their diets. Because of this, they may develop depression. In these cases, the addition of a minimal amount of sodium corrects the problem.

Because of the nutritional deficits that accompany aging, many people may overload themselves with nutritional supplements, in the hope that taking mega-doses of certain nutrients will keep them young and healthy forever. It is a good idea to ask about the nutritional supplements, herbs, and other self-medicating behavior the person is engaged in, as this is very common, and will not be mentioned unless you inquire. Supplements are not an alternative to proper eating.

Minor illness, such as the flu; dietary habits; tobacco or alcohol use; and other factors that can affect lab values are more likely to affect test results among the elderly. But because of the diversity that accompanies aging, even though lab values outside of these ranges should be considered as red flags for diagnoses, they do not necessarily indicate an abnormality, nor do results within these ranges necessarily rule it out.

Pain

The experience of pain in the elderly has been examined in two segments of the population — healthy older people, and those suffering with medical illness. The experience of pain is usually a consequence of injury or disease, conditions that are more prevalent in older people, which makes pain a significant detractor to quality of life. Although the elderly are more prone to painful illnesses such as neuropathy, trigeminal neuralgia, spinal degeneration, arthritis, and a variety of other degenerative diseases, there is actually little evidence that pain complaints are more common in the normal aged. Despite of this evidence, the fallacy persists that pain is an inevitable consequence of aging.

However, when it does exist, chronic pain will often cause impaired activities of daily living, depression, anxiety, lowered tolerance for frustration, problems with thinking and attention, sleep disturbances, and irritability

Unfortunately, the belief that all older people complain about pain can cause caregivers to ignore complaints of pain and sometimes overlook serious pathology, including life-threatening illnesses. Pain and suffering should never be equated with the processes of normal aging, but should be treated in an older person just as it is in the young.

In reality, elderly people may actually under-report pain because they too expect pain with aging. In addition, those with communication difficulties or confusion may be unable to make others aware that they are in pain.

The reporting of pain by someone who is not actually suffering is called malingering. A true malingerer consciously fakes pain in order to get medication, or to gain attention from family members or the healthcare staff. But even though many caregivers believe that lying about pain is common, research shows that in the elderly, feigning pain is actually very rare.

When a person says he is in pain, caregivers sometimes feel the need to decide whether they should believe a person who on other occasions has been untrustworthy. Although there is no accurate test to detect a malingerer, and in some cases we may disbelieve a person who claims to be in pain, professional responsibility dictates that we accept the report of anyone who states that he is in pain. It is better to treat a malingerer than to deny treatment to someone who is suffering.

A professional assessment of pain should never include a clinician’s personal biases, beliefs, values, or feelings about the person.

Pain is a completely subjective experience — there simply is no reliable way to objectively observe whether someone is in pain. Because pain cannot be observed, proved, or disproved, the only basis for pain assessment is the patient's subjective report that he is in pain. For this reason, the most useful criterion for definition is, “pain is whatever a person says it is, and exists whenever he or she says it does.”

In the 1986 edition of Cancer Pain Relief, the World Health Organization states unequivocally, “Believe the patient’s complaints of pain.” In other words, a report of pain by a patient should be sufficient to establish pain as a diagnosis. This means that it is the person reporting the pain, and not the healthcare team or the family, who is the final authority on the reality of pain.

Acute pain is useful in that it warns us that the body has sustained damage. The distress that accompanies pain causes us to withdraw from the source of the pain, and teaches us to avoid similar situations in the future. If tissue injury occurs, pain motivates us to seek help. It also tells us to remain immobile so that healing can occur.

However, chronic pain, also called unproductive pain, is not useful in any way. It only serves to diminish the quality of life. The distress from chronic pain serves only to make the person suffer. Chronic pain can sap enjoyment from a day, and eventually hamper one’s will to live — and it is the most common type of pain found in the elderly. About one out of five elders suffers from chronic pain, and in the long-term care population, the incidence of chronic pain can be as high as 80 percent.

Cicely Saunders, the founder of the hospice movement, was the first clinician to see that chronic pain was multidimensional. She felt that this type of pain was a problem of symbolic meaning. Chronic pain, she felt, can be experienced by the victim as never-ending, timeless, and meaningless. This experience often leads to despair, social isolation, and hopelessness. Hopelessness is the greatest predictor of suicide in chronic pain patients.

Saunders also believed that pain was not an event, but a situation in which the patients found themselves. Understanding this experience was facilitated by listening to the patients’ stories of suffering. She believed that this was often a portal to other problems which, when addressed, relieved suffering, Her concept of total pain treatment included exploration of the physical, psychological, social, emotional, and spiritual elements of the pain.

Treatment of pain included adequate pain medication combined with the exploration of the person’s experience. This is accomplished by listening to the person’s narrative about the experience, but also though exploring his or her worldview, which included artwork portraying the person’s predicament.

Saunders also pointed out a problem that still exists in treatment of the elderly — that 9 percent of terminally ill people who die in hospice report pain, while 20 percent of those in long-term care report pain.

The tolerance of pain is best defined as the duration and intensity of pain that the person is willing to endure. Pain tolerance, pain perception, and the expression of pain are all unique to the individual. Research shows that there is no such thing as a general pain tolerance. Some people just feel more pain than others do.

For this reason, the duration or severity of pain can’t be predicted. Simply put, you cannot be the judge of what should be painful to someone, or how long it should hurt.

Many caregivers believe that the more experience a person has with pain, the more endurance and the greater tolerance they will develop. In fact, people who experience chronic pain usually have a lower tolerance combined with a higher level of anxiety because they know how severe the pain can be and how hard it may be to get relief.

Furthermore, a person’s tolerance for pain varies from one situation to another. A person’s emotional state and degree of fatigue, and the value or meaning of the pain for that person all play a part in the tolerance to pain.

A person’s pain threshold is the point at which a stimulus is perceived as painful. Many caregiving professionals mistakenly believe that everyone perceives pain the same. In addition, over time, seasoned health-care workers often develop their own conclusions about the range of expected pain responses for certain situations. This can cause problems because a patient who experiences more pain than expected with a certain treatment, diagnostic procedure, or in a postoperative recovery period can become labeled as “exaggerating” his pain.

For example, surveys show that most nurses expect that the most severe pain following surgery will occur in the first 48 hours and then gradually subside. However, in a recent study of post-surgical patients, 31 percent reported significant pain after the fourth postoperative day.

Researchers Helme & Gibson have found that in healthy elders, pain threshold increases with age — with pain thresholds increasing about 20 percent by the eighties. Older brains seem to be less sensitive to peripheral input. Gastrointestinal pain threshold also rises significantly with age, and for this reason, warning signs of disease such as reflux or ulcers are often ignored.

However, pain threshold studies in the “older old” (age 80 years and older) show high within-group variance. In other words, the older a person is, the harder it is to predict his pain threshold. The perception of and reaction to pain in older people may be determined by other circumstances in their lives, such as stress, anxiety, and depression.

Arthritis is the most common source of pain in the elderly. Interestingly, in the oldest old, more people report the disappearance of joint pain than the onset of symptoms. This does not seem to be correlated with the severity of their disease. It also appears that the peak of musculoskeletal pain occurs after middle age. Arthritis and muscle pain does not improve with rest. In fact, rest can make the pain worse. Furthermore, a person loses one percent of his muscle mass for each day he remains inactive. Inactivity can lead to disuse syndrome, and may result in the person losing the ability to walk

Another common misconception among health care professionals is the belief that all pain must have an identifiable physical cause. Because we like to believe we have control, we believe that if a person has pain, there must be an observable cause. If we can’t find the cause, we inaccurately conclude that the person has no “real” pain. However, all pain is real, regardless of its cause and regardless of whether it can be diagnosed or measured.

Lack of a physical diagnosis causes some people to conclude that a person’s pain is psychogenic or “all in their head.” However, there is no evidence that purely psychogenic pain exists, and therefore all reports of pain should accepted as valid despite a lack of an observable, physical cause.

As a result of this widespread belief that all pain should be diagnosable, when there is difficulty establishing a cause for pain, the sufferers themselves may begin to question their own sanity. They may begin to fear they will be perceived as lying or malingering, and that pain relief will be withheld because their pain is not real. For this reason, it is useful to tell your patients that all pain is real, and will be recognized as such.

All pain includes both a physical and an emotional component. To have pain that is purely physical — that is, the experience of pain without distress (a condition called pain asymbolia) — is very rare. Therefore, feelings of fear and anxiety are appropriate reactions to pain, and shouldn’t be seen as evidence that the pain isn’t “real.”

All this being said, the social context in which the pain is occurring should be considered. Secondary gain from chronic pain — that is, the rewards one reaps from complaining of pain — includes increased attention from staff and family. In fact, in some cases, families and caregivers unwittingly encourage a sick role in a person, attending to him when he complains, and ignoring him when he does not.

For others, the expression of pain may be an attempt to cope with loneliness, fear of physical deterioration, or fear of impending death. Focusing on pain allows the person to avoid thinking about these unpleasant and frightening things. In these cases, behavioral intervention can be helpful.

Many health care professionals have been taught to look for visible physiological and behavioral signs that accompany pain, and therefore can be used as the basis for objective pain assessment.

With acute pain, physiological signs include elevated blood pressure, rapid heartbeat, rapid breathing, dilated pupils, and behaviors such as grimacing, moaning and flailing about.

With chronic pain, however, physical and behavioral adaptation occurs, resulting in periods where the person may show no overt signs of pain. As the body adapts to pain, vital signs normalize after a period of time. This return to equilibrium is necessary to prevent physical harm and stress on the body, but it does not necessarily mean the pain has disappeared.

When caregivers follow the acute pain model to assess pain, there will be times when a patient's behavior and physical signs do not correlate with the patient's report of pain. Patients may experience even severe pain without acting as if they are in pain. In other words, lack of pain behavior does not mean lack of pain.

A recent study shows the effect that behavior can have on pain assessment. In the study, nurses were told to rate the pain of two patients recovering from identical surgical procedures. Although the surgeries were identical, one of the patients smiled, while the other grimaced. Even though their behavior was different, the patients both reported that they had exactly the same amount of pain.

Interestingly, in both cases, many of the nurses underestimated the amount of pain the patents reported, but the estimates were even lower for the smiling patient. This indicated that the nurses had relied on their expectations of the patient’s pain and his behavior and appearance rather than on the person’s actual report of his level of pain.

In America, we have an unrealistic and stoic attitude about pain. Most of us feel that people should be able to cope with pain, and that to ask for help is a sign of weakness. This causes many caregivers to underestimate the severity of pain in those who report it, and to adopt the attitude that the person should “just learn to live with it.”

This attitude also causes many people in pain to refuse medication that could help them because they don’t want to appear to be “weak.” I have had many people tell me they don’t complain about pain because they want to be a “good patient,” or they feel that a stoic response to pain or exhaustion somehow makes them a better person

As a clinical psychologist, I have never been a strong proponent of medication, but I think we are very wrong-headed and ignorant about pain treatment in this country. Too many people suffer needlessly because of our negative attitudes about pain medication.

In addition, many physicians are reluctant to prescribe pain medication out of fear of repercussions from federal agencies, which also have this unrealistic attitude about medicating pain. A doctor who doles out pain medication liberally is often red-flagged, and called on the carpet for his or her “excessive” prescribing habits. This must change.

Another barrier to medicating pain is the unrealistic fear of addiction. Despite an abundance of evidence that narcotic drugs do not cause addiction in pain patients, many health care professionals persist in believing that addiction is a problem.

A survey of 1,781 nurses done in 1989 showed that 31 percent of them thought pain-killing drugs should not be given because of potential addiction. Because of this mistaken belief, many health care professionals continue to refuse these drugs to those who need them. Others minimize the amount of pain medication a person can receive, making the therapy useless. These attitudes are archaic and harmful.

Effectively eliminating pain can do wonders for a person’s quality of life. The priority for patients should always be comfort, not courage.

It has also been found that many chronic pain patients, including cancer patients, refuse to take opiate-based pain medication because they believe that they would develop tolerance to the drugs, and therefore the drugs would become ineffective. In reality, opioid drugs have no “analgesic ceiling” — that is, the level of these drugs can be increased to effective levels.

Finally, many health care workers underestimate the severity of the person’s pain, and overestimate the effectiveness of the medication they are giving. If a person who has received pain medication a few hours before claims that they are still in pain, they are often told, “I’m sorry, you just got a pain pill. You’ll have to wait two more hours.” This is equivalent to telling the patient that you think they are lying.

In the elderly, pain and depression may be closely linked — pain can be exacerbated by coexisting depression, while many who experience chronic pain often become depressed and anxious.

Studies show that up to 59 percent of patients requesting treatment for depression also complain of recurring pain, and conversely, 87 percent of patients coming to chronic pain clinics exhibit the symptoms of depression.

Even when people deny being depressed, they may exhibit the symptoms. In fact, most people are unaware of the symptoms of depression, and do not realize that depression can worsen pain. Common symptoms of depression include sleep disturbances, early morning awakening, psychomotor retardation or agitation, anorexia, and weight loss.

In some cases of unrecognized depression, complaints of pain may be the person’s way of explaining her loss of interest in life, her low energy, poor concentration, and guilt. In cases where pain complaints are accompanied by the symptoms listed above, behavioral interventions can help. Several studies have shown that chronic pain can cause cognitive problems. In fact, in one recent study, the central processing speed (the time it takes to think) in chronic pain patients was significantly slower than in head injury patients. Pain interferes with attention, concentration, and endurance, and can preoccupy a person to the degree that he cannot think clearly.

Interestingly, although cognitive impairment may be a barrier to pain assessment, it is important to recognize that even cognitively impaired residents reliably report the presence of pain when they are asked.

Medications

The elderly spend four times as much on medications than the rest of the population. People over age 65 comprise 12 percent of the population, but take 30 percent of all prescribed medications. The average number of drugs prescribed to people over sixty is fifteen per year. Two-thirds of this population is taking at least one prescription drug. Thirty-seven percent are taking at least five drugs, while another 20 percent are taking seven or more medications at once. The majority are also taking herbs, vitamins, and supplements.

In his book, The People's Pharmacy, Joe Graeden claims that thousands of cases of confusion, mood disorders, and memory problems are actually a result of the toxic effects of over-medication. He calls this problem the “spaced-out Grandma syndrome.”

This is not a small problem; in fact, it is estimated that over 200,000 people in this country are currently suffering from medication-induced mental problems. Each year, adverse reactions to prescription drugs, drug misuse, and medication abuse account for thousands of illnesses and deaths in the elderly.

One woman who came to see me was taking seventeen prescription medications! These drugs were given to her by several doctors for various ailments she had suffered over a period of years, but it seemed that no one had ever asked her if she was taking any other medication. Furthermore, none of the doctors told her when to stop taking the medication, so she continued to take medicine for ailments that had disappeared long ago.

Most people take any medication that their doctor recommends without question. The majority of the people I work with don't know the names of the medicines they are taking, or why they are taking them.

An adverse reaction is an unexpected and unwanted response to a drug that results in illness, organ failure, or death. Drug misuse is the under use, overuse, improper use, or erratic use of a medication. Drug abuse is the use of a drug for other than its intended purpose.

It’s important to understand that any drug that has a therapeutic affect can also have an adverse effect on a person. Unfortunately, up to 90 percent of people over 65 will suffer side effects from medication at some time in their lives.

Drugs act differently in older people. They are more prone to idiosyncratic and paradoxical reactions. The loss of brain cells and the lower amounts of neurotransmitters in the older brain can amplify the effects of many medications, and doses that are safe for younger people are often toxic in the aged.

Older bodies take much longer to metabolize and excrete certain drugs. Decreased liver and kidney functions increase the risk of drug toxicity. In short, all medications should be given with care and be closely monitored. In many cases, dosages need to be decreased.

For these reasons, any symptom in an elderly patient should be considered to be a drug side effect until proven otherwise.

The medical community has not done an effective job in tackling this problem. Almost 65 percent of elders are not told by their doctors about precautions in using medications, and 67 percent are not told anything about possible side effects.

In many cases, the prescribing physician did not know about the potential adverse effects of the medication, and was not aware of the interactive effects it could have with other medications the patient was taking.

Over a third of elderly people make serious mistakes in taking their medication — either forgetting to take it or forgetting that they have taken it, and therefore overdosing.

Even worse, about 12 percent of people taking prescription drugs are using medications that were actually prescribed for someone else. They accidentally take medicine that is not their own because they can’t read the label, or because they got it from a friend who said it “worked for him.”

Although most people do not realize it, many over-the-counter medications can also significantly interfere with memory, mood, and thinking. Even so, few if any of these medications indicate cognitive impairment as a side effect. Doctors don’t often explain to their patients that the drug they are prescribing may have an effect on their memory or thinking.

In addition to experiencing problems with drugs, many people resort to alternative medicines, vitamins, herbs, and other over-the-counter remedies to help them with their various maladies. This becomes problematic because most people don’t let anyone know what they are taking.

Always ask the person to tell you about everything they are taking. Ask them about prescription drugs, non-prescription drugs, vitamins, herbs, nutrients, and other alternative remedies. Ask them about any allergic reactions or adverse symptoms they have experienced in the past. If you don’t ask, you will not be told.

Misuse is using a drug improperly, which may include overuse, use for the wrong reason, or using a medication when it is no longer needed. Commonly misused prescription drugs include sedative-hypnotics (sleeping pills), anti-anxiety agents (such as valium and xanax), and analgesics (such as oxicodone). When misuse rather than abuse is suspected, drug education groups and clear instructions about the use of the medication are usually effective interventions. When a person is abusing a drug, however, things get more complicated.

The elderly not only use prescription drugs three times as frequently as the general population but also have the poorest rates of compliance with directions for taking medications. For these reasons, abuse of prescription drugs may actually be the most common type of drug abuse.

Because of changes in metabolism, and kidney and liver function, older people should be prescribed lower doses of medications. Despite this, data from the Veterans Affairs Hospital System suggest that elderly patients routinely are prescribed inappropriately high doses of benzodiazepines, and that the drugs may continue to be prescribed for longer periods than in younger adults, which results in overdosing, inducing altered consciousness, and increasing the risk of dependence. Because of this, Valium (diazepam), Xanax, and Dalmane (flurazepam) are some of the most common drugs of abuse in this population.

There is a sex bias problem in prescribing medications that further exacerbates problems. Studies show that women are more likely than men to be prescribed narcotics and anti-anxiety drugs — one study touting a 48 percent higher likelihood. Women are also two times more likely to become addicted to sedative, hypnotic, or anti-anxiety medications.

Cognitive impairment often occurs with benzodiazepine use, manifesting as symptoms that mimic and are often mistaken for dementia. But worst of all, elders who take these medications are at increased risk for falls that can result in hip and thigh fractures (as well as for vehicle accidents). In fact, these medications are the number two cause of falls in the elderly. Hip fracture can be lethal in the frail elderly. Of those who do survive, many undergo hip surgery, which frequently results in significant irreversible decrease of mental status.

Substance Abuse

Substance abuse among the elderly is a very common but often undetected problem. Older people rarely seek help for drug problems.

Even though the elderly are at highest risk for drug misuse and abuse, the problem is chronically under-diagnosed. Although it is not well known to the public, alcohol-related problems in the elderly cause as many deaths as heart attacks.

Initial research on elder substance abuse suggested that the prevalence of alcohol abuse and dependence in adults 65 years of age and older was low — about 2 to 5 percent for men and about one percent for women. Other studies estimate that between 2 and 10 percent of individuals over the age of 60 suffer from alcoholism, and in a survey of elderly patients in Washington State, 9.6 percent were diagnosed with alcohol abuse, while about 5 percent were referred for prescription drug abuse.

However, since that time researchers have discovered that these numbers are probably an underestimation because the majority of substance-abusing older people lie about drug and alcohol use, and deny any problems when asked. In surveys of drinking habits in the elderly, those who admitted drinking routinely under-reported the amount of alcohol consumed.

It is easier for the elderly to conceal their drinking because they don’t work, have few social commitments, and may avoid social contact without consequence. Recent research suggests that retirement communities may foster substance abuse because the communities isolate elders from the general population, and a person who does not interact with others in the community is seldom scrutinized. Because people who live in these communities buy or lease their property after they retire, the community is made up of strangers. There are few, if any, long-term friends who would notice changes in behavior. They are not monitored and have no obligations or responsibilities, and therefore can stay in their homes intoxicated for long periods of time with no social consequences.

Chronic alcohol consumption leads to medical and psychological problems. For example, excess alcohol consumption is linked to malnutrition, because heavy drinkers seldom eat a balanced diet. Chronic consumption of alcohol also decreases the ability of the stomach to absorb nutrients. Another alcohol‑related problem is osteomalacia, or thinning of the bones. Over time, drinking results in cirrhosis of the liver, which is now one of the eight leading causes of death in older adults.

The most frequent and serious problem with chronic alcohol use in older adulthood is a decline in cognitive functioning. Chronic alcohol abuse may lead to major declines in memory and information processing.

Over many years of alcohol abuse, the effects of these physical and cognitive changes lead to significant impairment in most persons who survive past middle age. The same is true for those who begin to drink heavily in later life.

There is 60 percent correlation between prescription drug abuse and alcoholism. Psychosocial factors such as loneliness and depression, and health factors related to the aging process, such as pain, disability, or chronic disease, are the major contributors to alcoholism and drug abuse in older people. Combining alcohol and drugs, especially tranquilizers and sleeping pills, is especially dangerous, as there may be a cumulative depressant effect on the central nervous system.

Risk factors for alcohol abuse among all adults include genetic predisposition, being male, limited education, low income, and a history of psychiatric disorders, especially depression.

Stressors are more important contributors to late onset alcohol and drug abuse than to early onset abuse. Common stressors that contribute to alcohol and drug abuse in later adulthood include retirement, relocation, conflict within the family, financial concerns, physical health problems, and death of a spouse. Older widowers have the highest prevalence rates of alcohol abuse among older adults.

The stigma attached to chemical dependency problems in older persons fosters denial and makes it difficult to determine the extent of dependency. Individuals often enable their chemically dependent spouses out of a sense of duty, thus increasing the likelihood of denial.

The elderly are often viewed as poor treatment risks because society sees them as physically, mentally, and economically unstable. However, successful treatment and recovery are highly possible for this population if intervention and treatment are positive and get to the root of their problems. During intervention and treatment, it is important to build social support networks for the elderly. Programs that reinforce skills and focus on reducing isolation decrease the risk of relapse. Involving spouses and other family members in the treatment process will educate everyone about the effects of chemical dependency on the older person, and its effects on family relationships.

A thorough assessment is essential to detect and correct drug misuse and to diagnose drug abuse. Prior to considering any medication, the person must be screened for alcohol and drug use, as this will cause medical complications and put the person in peril. Ask about an individual or family history of alcohol or other drug abuse.

Sexual Problems

Contrary to popular belief, sexual behavior continues throughout the lifespan. In this culture, the belief that elderly people should be nonsexual is especially true about older women. Studies show younger people look unfavorably on aging women as being physically attractive and sexually active. This set of values does not apply to older men.

The greatest barrier to sexual activity in the elderly is lack of an available partner. In the 65-74 age group, only 9 percent of men are widowed but 42 percent of women are. Older women are also less likely to remarry, while elderly single men often marry younger women.

In addition, elderly women experience more losses at widowhood than do elderly men. Many women tie their identity and self-esteem to marital roles, while most men tie their identity to their work.

Retirement is also a problem. Because many men do tie their identity to their work, retirement often brings on depression and adjustment disorders, which can make life difficult for both partners. Another problem is the significant change in time spent together, and the concomitant disruption in lifestyle and routines. Marital conflict often increases, anger and hostility emerge, and, consequently, sexual desire may lessen.

The strongest predictor of the frequency of sexual activity in the elderly is the level of activity in their younger years. The marketing of medications to increase potency has increased the frequency and enjoyment of sex for thousands of elders, however, it has also increased the risk of stroke and heart attacks, as the vascular insufficiency that impaired erections may be indicative of cardiovascular disease.

It’s important to note that the rates of HIV infection are growing rapidly in the population. Currently 10 percent of HIV cases are found in people over 50, and 5 percent of cases are in those over 65. Between 1991 and 1996, the increase of HIV was 97 percent in men over 50 and 106 percent in women over 50. This may be in part because lack of concern about pregnancy lessens the perceived need for safe sex.

Older people are rarely checked for syphilis. Tertiary syphilis can present as dementia and should always be considered as a cause of cognitive disarray.

	Mental Retardation	2.82 percent
	Depression	42.79 percent
	Psychiatric Diagnosis	18.76 percent
	Dementia	45.35 percent
	Behavior Problems	30.62 percent