This is a beginning to intermediate level course. After taking this course, mental health professionals will be able to:
This course on aging is intended for all clinicians wanting to understand the mental health problems of older adults, most who are using professional care. This course also meets the mandatory requirements for license renewal for psychologists, LCSWs, and MFTs in California.
The United States 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 our 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 those over 65 to the total population jumped from one in twenty-five to one in eight.
By 2020 older people will outnumber children. By 2030, that number of people over 65 will reach 85 million. Worldwide, the number of people over 65 is increasing at about 870,000 every month. 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 is tripling every five years. By 2025, 1 in 26 Americans can expect to live to age 100, compared to 1 in 500 in 2000.
During this time, the number of older Caucasians will increase by 97 percent, African Americans by 265 percent, and Latino Americans by 530 percent. Ethnicity will be an important variable in treatment some cases.
Two major forces are driving this trend.
During the decades while the boomers were growing up, breakthroughs in public health, 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.
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.
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.
Unfortunately only 3% of seniors with mental health problems get treatment from mental health professionals. Few get psychotherapy, and most get psychotropics from primary care physicians.
Geriatric mental healthcare is based on the premise that older adults have unique psychological needs. 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 and treatments take on a different approach.
Although most adults live independently in their home, many are living in long-term care facilities. The majority of these people (up to 90 percent) in this setting will be suffering from mental, emotional, or behavioral problems. 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.
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. The aging population will increase the number of people in nursing homes 300% by 2030.
“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.
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 mental disorder.
Currently in many states, long-term care facilities house the bulk of the elderly mentally ill. Since the deconstruction of the state mental health systems, 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 mental hospitals, 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
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.
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 times from illness. The immune system may decline, causing changes in interleukins which can alter mental status for months after an 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.
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 substantianigra 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.
About 85% of people who die from coronary artery disease or stroke are over 65. But in spite of its high prevalence, only 10 to 20% over 65 will be clinically diagnosed with vascular disease.
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.
Unfortunately a many older adults were long-term smokers, and therefore will be suffering from both vascular and lung problems, both of which impair brain function.
Recent research done in Europe by AlewijnOtt 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.
Be aware that many older adults are taking statin drugs. These drugs are known to cause mood disorders and significant cognitive problems. In the elderly, lowering cholesterol is related to all-cause mortality elder adults, even when adjusted for other health status or indicators of frailty.
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, Bernice 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).
Researchers Daniel Mroczek and David Almeida at Fordham University 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 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.
Jim Stevens brought his father to the nursing home because caring for his dad was disrupting his job to the degree that he was at risk of being fired.
He told the administrator that he wanted to be notified of any and every problem his father was experiencing. He made it clear that no treatment of any kind was to be administered to his father without his approval.
In reality, Mr. Stevens was very difficult to reach. He seldom returned phone calls, and sometimes could not be reached at all. This resulted in impeding any semblance of quality care.
The administrator invited Mr. Stevens to a meeting and said, “Mr. Stevens, I know you care for your father a great deal. I know you worry about him. And we are all impressed with your concern and your involvement. It is true that you want the absolute best for your dad, isn’t it?”
“Of course,” he replied.
“Well the absolute best care we can give requires immediate intervention at times. If we have to wait, your father may suffer unnecessarily. You wouldn’t want to stand in the way of helping him, would you?”
“No. Of course not,” he said.
“Then I guess we both agree that when we cannot reach you, we should do what we feel is in your father’s best interest, right?”
“I suppose so,” he said.
“Great,” She said, “then I would like you to sign this agreement stating that if we cannot reach you within an hour, we can do what is best for him.”
In this interchange, several things happened:
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:
Mrs. K, a profoundly demented 76-year-old Jewish widow, was transferred from a long-term care facility to the Cornell Medical Center for an evaluation of agitated behavior including constant pacing, verbal abusiveness, and at times, combativeness.
Although Mrs. K had exhibited symptoms of Alzheimer's disease for approximately one and a half years, she had worked in her family's garment manufacturing business until one year before her transfer to the Center.
In the transfer summary, the nursing home complained of difficulty with the patient's 50-year-old son, who was running his mother's business.
During the initial phase of his mother's hospitalization in our facility, Mr. K was unable to accept his mother's progressive deterioration and was insistent that certain signs, such as intact long-term memory, were proof that she was less impaired than he had been told. He believed that his mother's wandering stemmed from her boredom at not having work to do and from the lack of staff engaging her in activity.
Mr. K visited his mother nightly and brought her dress patterns to cut. When she was unable to perform the tasks he expected of her, he displaced his disappointment and anger onto the nursing staff in a hostile, abusive, and accusatory fashion, thus engendering staff defensiveness and resistance to empathizing with his pain. Mr. K was critical of all aspects of his mother's treatment and expected the hospital to find a miracle cure for her illness.
Engaging Mr. K in family therapy was difficult since he saw both the doctor and social worker as his adversaries. He was seen in weekly sessions, where he was encouraged to talk about his frustration at our inability to make his mother well.
At the same time, we educated him about Alzheimer's disease – its manifestations, course, and treatment.
Mr. K eventually revealed his concerns that the illness was hereditary or contagious, and his feelings of helplessness in caring for his mother. He had attempted to have her live with his family before placing her in a nursing home, but he and the family were unable to control her wandering and disruption of family life.
As Mr. K began to discuss his family history and his feelings about his mother, it became clear that he had a conflict-ridden, ambivalent relationship with her.
Mrs. K had worked long hours in the family's business since Mr. K was a young child and had left his care to an older sibling. Mr. K had felt neglected and abandoned, and had developed angry feelings toward his mother.
Having to put his mother into a nursing home reawakened these repressed feelings of anger and abandonment, and aroused concerns that he was now abandoning her. He was still unable to see his mother as anything other than the strong, capable, working woman he had known in the past, and although he was capable of running the family business, he was experiencing self-doubts. In addition, he was furious at his sibling, who lived out-of-town and was not involved with his mother's care.
Mr. K's reminiscences about his mother helped him to realize the source of his angry feelings and he became less critical of the staff.
His lessened anger enabled him to understand the symptoms of Alzheimer's disease, to more realistically assess his mother's illness, and to mourn her loss.
When Mrs. K was discharged from our facility, we talked with the social worker in the long-term care facility where Mrs. K would return, so that we could apprise her of Mr. K's conflicts and encourage her to provide him with continued support.
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.
Family Visits in long-term care
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.
Mrs. Whitkin’s daughter would visit twice a week. She would arrive at ten o’clock, and spend an hour with her mother. During these visits, Mrs. Whitkin would complain incessantly about not being fed, not being cared for, and being generally neglected.
We suggested to her daughter that she come to the facility unannounced at different times during the day and stand where her mother could not see her, so that she could observe the things we did for her mother. In this way, she was able to see that we were in fact doing the things that Mrs. Whitkin claimed we did not do. The daughter then realized that much of what we were doing was simply forgotten.
Working with families
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.
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.
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 three top unrecognized conditions are constipation, urinary infection, and hypothyroidism.
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.
Body Image 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 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.
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.
Psychotherapy is very useful in improving the quality of life of older adults. However, 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. Therefore, a nutrition assessment should be done before any intervention.
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 ethnic 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 BerendDeijen 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.
Mr. R arrived in the emergency room with a questionable new stroke. He was dehydrated and had lost 50 pounds. He was unable to walk and was incontinent of urine and stool.
During assessment, the patient confided that he felt he was a burden to his wife. He was embarrassed regarding his loss of continence and felt badly that his wife “had to clean him like a baby.”
Mrs. R thought that Mr. R was doing this on purpose. Thus, she would restrict food and fluids to decrease the frequency of the episodes of incontinence.
Cases of neglect like this often come to light when a patient improves rapidly in the hospital, and again deteriorates when returned home.
B12 and Folic Acid
Folic acid and B12 levels are 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 B12. 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 B12 into 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.
Niacin, Biotin, Pantothenic Acid
Both niacin (vitamin B3) deficiency and biotin deficiency can cause or exacerbate depression, anxiety, 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.
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 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 believes 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 through 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.
The Causes of Pain
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.
Attitudes about 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.
Pain and Depression
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.
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 older adults will take any medication that their doctor recommends, without question. The majority do not 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 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.
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.
With increasing age comes a change in sleep. In general, older adults take longer to fall asleep, have multiple nighttime awakenings, and require more daytime naps. The most common sleep complaints in the elderly are difficulty sleeping throughout the night, waking up earlier than they would prefer, and feeling that they have not gotten enough rest.
Other common phenomenon is a circadian drift into becoming a “morning person.” There is a tendency to go to bed earlier and wake up earlier. Nevertheless, for many, even when they do go to bed at the same time that they did when they were younger, they will wake up earlier, thus depriving themselves of adequate sleep.
Loss of hearing and sight can also disrupt sleep. For example, many blind people have a free-running biological clock, which causes regular periods of insomnia and hypersomnia every three weeks, because sunlight does not rest their biological clock.
Older people with sleep problems experience a diminished overall quality of life. There is also a greater prevalence of depression and anxiety. Older people who have sleep complaints also show slower reaction times, problems with balance, and impaired memory. Cognitive function is also impaired, and sleep problems may be misdiagnosed as dementia.
Insomnia is very prevalent in people experiencing stressful life events including loss, bereavement, or a move. As these events are common in the long-term care population, they should always be considered as primary causes of sleep disturbance.
Other common factors that affect sleep include noise, uncomfortable temperature, lighting problems, and bedding. Many studies in sleep problems in the elderly point to these factors, particularly in a long-term care setting, where people may share a room with others who have different sleep cycles, who snore, or make noise during the night. Temperature, light, and bedding preferences are seldom asked about or attended to, and cause uncomfortable sleep environments.
A common and potentially dangerous sleep problem in the elderly is sleep apnea. This is caused by an obstruction in the airflow during sleep. A person suffering from apnea may actually stop breathing for more than a minute. Most people with sleep apnea snore, and sleep poorly. During the day, they are fatigued and listless. This in itself is troubling, but even more troubling is the mounting evidence that apnea can cause dementia.
Sleep researcher Sonia Ancoli-Israel found that among 235 nursing home patients, virtually all with severe sleep apnea were also severely demented. Seventy percent of the patients had five or more respiratory disturbances per hour of sleep and 96 percent showed some dementia. Sleep apnea was significantly correlated with all subscales on the dementia rating scale.
Mild to moderate apnea caused no problems, but the study showed a strong relationship between dementia and sleep apnea when the sleep apnea and dementia are severe. It is thought that sleep apnea causes deficits in brain function, possibly due to global effects rather than any particular cortical or subcortical structure. If this is so, treating residents for apnea could significantly reduce dementia symptoms. Fortunately, this condition can usually be remedied.
Still another concern is the finding that sleep apnea, or any type of breathing abnormality during sleep, has been shown to increase the level of agitation in people suffering from dementia.
Delirium, also called acute confusional state, is most often caused by acute illness or drug toxicity, and always involves periods of diminished consciousness. It may also be caused by fever, organ failure that leads to toxicity, or any acute infection. The most frequent cause of delirium in older people is a urinary tract infection, and this should always be assessed and ruled out when establishing the cause of diminished cognition. The delirious state is usually transient and fluctuates in intensity throughout the day.
Delirium is a sign of danger, and if not treated, often is a warning sign of death. In the majority of cases, the person recovers within a few weeks. However, in elderly patients, delirium lasting up to 6 months is not uncommon, especially when arising because of chronic liver disease, a carcinoma, or endocarditis. This prolonged delirium is sometimes mistaken for dementia, but the differential diagnosis is the observation of fluctuating level of consciousness.
A majority of older people will develop confusion or delirium just by entering a hospital. They may also decompensate when relocated.
Findings from the 2000 Medical Research Council Cognitive Function and Aging Study suggest that the relationship between “normal” brain aging and the dementias is best represented by a continuum. In the study, the brains of 209 older people (of which 100 met the clinical criteria for dementia) were examined to distinguish a normal aging brain from that of one suffering from dementia.
Brains of demented and non-demented subjects overlap in the amount of vascular lesions, plaques (found in all Alzheimer’s disease patients), and plaque density. Studies show that no single pathological criterion reliably distinguished between demented and non-demented groups. While vascular lesions did not provide sufficient explanation for the presence of dementia, they did suggest that the interaction between Alzheimer’s pathology (plaques and tangles) and vascular insufficiency is the strongest determinant of the onset of dementia. The concept of a continuum has been suggested by many researchers, who believe that cognitive and memory deterioration can be divided into three broad categories:
Age-associated memory impairment (AAMI) is a gradual decline in encoding new memories and retrieving old ones. People who experience AAMI have subjective memory complaints disturbing everyday life.
The most common manifestations of AAMI are benign but bothersome difficulties such as forgetting names, losing belongings, difficulty recalling a list of multiple items, and problems with tasks that require multiple actions. There also may be difficulty remembering telephone numbers and zip codes. If the individual is distracted in some way, the problem is compounded, making it even harder to remember things such as what he intended to buy at the store.
AAMI may also manifest itself as subtle deficits in executive functions associated with frontal lobe function. This may slow thinking, reduce tolerance for frustration, and cause the person to seek reduced levels of stimulation. The Alzheimer’s Association and the American Health Care Association are currently studying AAMI to determine whether those with age-associated memory impairment will eventually develop Alzheimer’s disease.
Although this research is ongoing, most researchers now consider age- associated memory impairment to be a benign condition which is not a predicator of dementia – AAMI seems likely to be a phenomenon of normal aging rather than a continuum from normal aging to a pathologic state such as Alzheimer's disease.
A survey sponsored by General Nutrition Centers revealed very low awareness of AAMI among those who may suffer from the condition. Although AAMI is a very real condition, the majority of survey respondents (71 percent) had never heard of it. Two-thirds of the respondents insisted they did not suffer from it even though they reported such typical symptoms as forgetting names, phone numbers, day-to-day tasks, and even important events.
Researchers do not yet know the exact cause of age-associated memory impairment. However, there are things that contribute to memory change and/or loss. One of the causes is chronic lack of mental stimulation. Findings suggest that if a person becomes more mentally active and takes steps to keep her brain healthy, memory will improve.
Because AAMI and Mild Cognitive Impairment (MCI) are relatively new concepts, researchers are still attempting to define and delineate the terms. MCI is considered to be more serious than age-associated memory impairment, but not as serious as dementia.
An example of the difference between the two would be a person with AAMI occasionally forgetting the name of an acquaintance for a few seconds. In contrast, a person with MCI would repeatedly struggle to remember the names of close colleagues, which might begin to interfere with his everyday life.
Other signs of MCI include difficulty in forming memories of events that just happened. On a recall test, a person may be able to repeat a string of unrelated words, but then fail to remember even one of them 10 minutes later.
No one knows how many people experience this condition. While an estimated five million Americans have Alzheimer’s disease, studies to determine the incidence of this milder deficiency are only starting.
Unlike AAMI, Mild Cognitive Impairment is now thought to be a condition that frequently precedes Alzheimer's Disease. It is defined as a transitional phase between normal aging and dementia. One study estimates that between 30 and 50 percent of persons who develop Mild Cognitive Impairment will contract Alzheimer’s disease within five years.
Individuals confronted with this prediction may feel as though they are numbers on a roulette wheel, and if theirs comes up when the spinning stops, they are fated to lose their memories. While acknowledging the importance of new studies that give physicians a clearer picture of how many new victims of memory loss to expect, I believe that such announcements create unrealistic fears because they offer no alternatives.
The truth is that if MCI can be detected, it may be treatable. Preliminary data suggests that people with MCI should begin intervention and treatment as soon as the diagnosis is made.
Currently, the government's National Institute of Aging is engaged in a multi-university study to test the effectiveness of drugs (e.g., Aricept™), and natural approaches including vitamin E, ginkgo biloba and others. Therefore, while the predicted statistics may be accurate, at least half of those who develop MCI can not only overcome it, but may also prevent the onset of Alzheimer’s by using corrective measures.
The word dementia means literally to lose one’s mind. Dementia is a syndrome of brain dysfunction characterized by multiple deficits in cognitive abilities without loss of alertness (a loss of alertness occurs in delirium).
In 1900, there were 3 million people over 65 in the United States. At the time of this writing, there are about 35 million, and this number is expected to double by the year 2050. It is estimated that one percent of people between the ages of 65 and 74 years old, seven percent of those from 75 to 84 years old, and twenty-five percent of those over 85 will suffer from severe dementia. Currently about 2 million people in the US suffer from advanced dementia, while another 5 million suffer mild-to-moderate symptoms. However, these data may be underestimates, as some researchers feel that more than half of the people suffering from dementing illness are never diagnosed.
Dementia is caused by brain damage. The parts of the brain that are most affected are the association areas of the brain, which integrate sensory information, thought, memory, and purposeful behavior. When extensive damage to these regions occurs, the person may begin to engage in bizarre behaviors that have no external link to the environment. They may also become verbally and physically agitated and abusive.
Dementing illness always includes the loss of memory and cognition. It also causes the loss of the ability to make sound judgments, and to maintain an ongoing sense of being. Very often, the ability to comprehend and express ideas is also impaired. In addition, there are problems with social interaction, daily living skills, and thinking.
There are over 60 known disorders that cause dementia, but Alzheimer's disease, which is also often referred to as Dementia of the Alzheimer's type (DAT), accounts for over half of all cases. Vascular dementia (previously called multi-infarct dementia,) accounts for another twenty percent. Fronto-temporal dementias, (including Pick's disease) account for about 5 percent.
Criteria for the diagnosis of dementing illness are:
Although dementia is usually thought of as a chronic, progressive loss of mental function, many people suffer from potentially reversible dementias caused by brain tumors, thyroid problems, low testosterone, infections, toxins, nutritional deficiencies, overmedication, metabolic problems, and other neurological disorders. While potentially reversible dementias make up about 20 percent of cases, in a recent meta-study, only 0.6 percent of dementia cases actually reversed.
However, there is evidence that one out of four older people diagnosed with dementia does not have it. This is often because of sloppy diagnosis, or confusing medical or psychological disorders with dementing illness. It is also important to distinguish the existence of a mental disorder from the symptoms of dementia, because mental disorders often mimic the symptoms of dementia but are often treatable. In addition, when a person is suffering from dementia, the existence of a mental disorder may worsen the symptoms.
While cortical dementias such as Alzheimer’s usually cause aphasia (loss of language skills including word retrieval), apraxia (problems with motor programs), and agnosia (trouble identifying and naming objects), subcortical dementias most often present with intact language and visuo-spatial function. Subcortical dementias include Parkinson's, normal-pressure hydrocephalus (NPH), multi-infarct dementia, Huntington’s disease, and Binswanger’s disease. Of these dementias, only normal-pressure hydrocephalus is potentially reversible.
THE STAGES OF DEMENTIA
If you have ever walked into a room and realized you had no idea why you were there, you have an inkling into how demented people experience their entire day.
In the early stages of dementia, the loss of ability to think and remember becomes intermittent and patchy – the afflicted person may forget who you are on Monday, but have no trouble recognizing you a day later.
A person in the early stage of Alzheimer's disease may begin to show a loss of interest in his environment and in his personal affairs. Word-finding becomes difficult, usually beginning with the inability to remember names, and then nouns. He may have difficulty in attending to important social events, such as holidays or birthday parties. Social graces, politeness, and social protocols begin to break down. For example, one of my patients went home in the middle of his birthday party because he did not remember why he was there, and decided it was time to take a nap.
People in this stage suffer uncertainty and confusion in initiating actions. A thought occurs to the person to do something, but a moment after they begin, they have forgotten what they intended to do. They may pick up an object with clear intent, and find themselves wandering around with it, not remembering what they meant to do.
At this stage of the illness, people may be able to live at home with supportive care. But even though they appear to be thinking clearly, they will usually need assistance in paying bills and managing money. Frequent assistance is especially important if the person lives alone.
Proper health care, vitamin E, Vitamin B12, non-steroidal anti-inflammatory drugs, and anticholinesterase inhibiting drugs – along with the reduction of environmental change and stress – can reduce symptoms, slow the disease process, and prolong independence at this stage.
Although a person in this stage of the disease may still be able to drive, he may become easily lost, and forget his way home. Neighbors and friends can assist by being aware of any change in living habits that warrant increased vigilance. Relocation, change in residence, or illness will often be the point at which the patient slips into the next stage.
As dementia progresses there is a loss of what health care providers call activities of daily living (ADL). Health care and personal hygiene are neglected. The person shows diminished ability to care for personal needs or affairs. There is also a loss of ability to comprehend, remember, or follow simple directions. As motor programs begin to break down, the person may engage in meaningless behavior.
There are obvious memory problems in recall, recognition, and retention. As memory loss continues, most of the simple tasks of life – like bathing, brushing teeth, or getting dressed – become confusing and incomprehensible, and require aid from others. Even something as simple as putting on a shirt may become overwhelming.
Biological clocks begin to falter, and time disorientation occurs to the degree that the person may not be able to tell if it is day or night – the person wakes at midnight and asks for lunch. Appointments are forgotten and personal possessions are lost or sometimes hoarded and hidden.
Because there are severe deficits in the ability to think and remember, business affairs must be turned over to a conservator or family member with power of attorney. At this point, families may still be able to care for the person, if there is support from its members. If a support network is not in place, most families find the caregiving overwhelming, and a higher level of care is required. This type of behavior is often the reason for a referral to a long-term care facility.
As the disease progresses, screaming, wandering aimlessly, and combative behaviors often appear. The person in the later stage of Alzheimer's disease is no longer able to find his way from one point to another. He often is disoriented as to time and place. His ability to recognize people becomes impaired, and he may mistake a caregiver for a family member. Fine motor skills, such as the ability to write or manipulate objects, are lost. The person now needs help with eating, getting dressed, and toileting.
Speech becomes garbled and incoherent and nonverbal communication must often be used. A compulsive need to touch everything, to hoard everything, and to examine all objects with the mouth begins to emerge.
There is sometimes a complete loss of emotion. Dietary habits change, ranging from anorexia to binge eating. The person may exhibit inappropriate sexual behavior. Even with all of these problems, a person in this phase may still be able to engage in, and enjoy. physical activities such as walking and group activities, and will still enjoy music.
By this time, behavior patterns literally fall to pieces. Motor sequencing programs are shattered into fragments. The person may suddenly get up, stop, look around, touch the wall, and sit down again without having the slightest idea what she is doing.
In this stage, the person requires 24-hour care. Placement in a care facility may become necessary. When this is done, the lack of familiar surroundings and faces often results in a total loss of orientation. Personal hygiene is done entirely by a caregiver. Sleep becomes severely impaired, and agitation and confusion often occur upon awakening and before bedtime.
In the end stage of this cruel siege, the individual may lose the ability to walk or stand up, and the ability to communicate in any meaningful way. The terminal stage requires total nursing care. The patient is dependent on support for all physiologic processes. He is non-responsive and cannot recognize family members or familiar objects. Further deterioration is usually halted by death from an infection, renal failure, or pneumonia.
Losing a loved one to this disease is a painful and devastating process. Family members undergo prolonged anticipatory grief and require frequent support from the staff and from each other. Some family members may not be able to tolerate seeing the mindless, ravaged body of a person who no longer recognizes them. Occasionally, to protect themselves from the pain, they stop visiting the patient. Supporting the family members is vitally important in preventing abandonment at this time.
Depression and anxiety are the most prevalent, and also the most misdiagnosed, emotional disorders in the older population. Together, these debilitating disorders will impair the quality of life and shorten the lifespan of millions of adults. In fact, the World Health Organization ranks depression as the number two cause of mortality in older people and predicts that by 2020, depression will rank second only to ischemic heart disease in terms of disability.
In healthy adults, depression beginning late in life is uncommon – less than two percent of the healthy elderly suffer from late onset depression. Despite the occasional inconveniences that accompany aging, most older adults actually experience an increase in life satisfaction.
On the other hand, depression is rampant in older people who are medically ill. The greater the severity of the illness, the more likely it is that a person will become depressed.
For this reason, depression in the elderly is seen largely among disabled, hospitalized, and long-term care patients.
Depressive symptoms are found in 40 to 50 percent of nursing home and geropsychiatric hospital residents, and in a recent study of several nursing homes, major depression was found in 25 percent of the cognitively intact residents and 10 percent of cognitively impaired residents.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) emphasizes emotional symptoms such as sadness and anhedonia as the quintessential criteria for the diagnosis of depression. However, in the elderly, physical symptoms may be more prevalent.
In fact, in one study of 1146 patients with major depression, physical symptoms were the chief or exclusive complaint for 69 percent of those identified. These symptoms include headache, back pain or nonspecific musculoskeletal complaints, weight loss, constipation, a bad taste in the mouth, lack of interest in sex, and insomnia. In addition, physical symptoms that are not usually associated with depression, including gastrointestinal complaints, are also common. One study of irritable bowel syndrome showed markedly higher rates in depressed patients versus controls.
When emotional symptoms are reported, they are most likely to be complaints of agitation, anxiety, panic attacks, irritability, and obsessive concern with bodily functions.
Despite the high prevalence of depression in the medically ill elderly, sufferers seldom admit to being depressed, and rarely seek treatment.
Depression’s impact on health
Heart disease and stroke are the leading causes of death and disability among older Americans today. Depression is associated with increased mortality in patients with ischemic heart disease activation. Although cardiovascular disease is linked to many factors – such as sedentary lifestyles, hostility, cynicism, smoking, and alcohol abuse – the presence of depression is the most potent predictor of mortality.
Studies show that even when the effects of smoking are controlled, depression remains a significant independent predictor of mortality among heart patients and stroke survivors. The relationship between depression and heart disease is reciprocal, with each condition exacerbating the other.
In 1905, German psychiatrist Robert Gaupp coined the phrase arteriosclerotic depression after observing that many elderly depressed people also showed hardening of the arteries. Felix Post also suggested that vascular disease in the brain was a significant factor in the development of depression in late life.
With the advent of computer tomography (CT scans) and magnetic resonance imaging (MRIs), it has actually become possible to evaluate vascular changes in the brain of elderly patients with depression. These changes are seen as hyper-intense signals in both the white matter and the gray matter.
In 1988, Dr. Ranga Krishnan found that over 70 percent of patients with late-onset depression (defined as depression with its onset over age 50), had hyper-intense signals on MRI images that are indicative of small strokes. The main locations of the gray matter changes were in the basal ganglia, in the caudate and putamen, the cingulate gyrus, and in the frontal lobes of the brain – areas that mediate mood and executive function.
It has long been known that many people with depression exhibit low levels of serotonin. Recently, it’s been suggested that the link between vascular disease and depression may be because blood platelets and brain neurons share the same serotonin transporter protein, and are moderated by the same gene.
Other research suggests that this link has a genetic component – that is, depression often runs in families. Even in people without heart disease, platelet activation (the process in which platelets stick to one another and to tissue, forming a plug or clot) is increased in late-life depression, and is most often found in elderly depressed subjects with a 5HTTLPR l/l genotype. Several studies have linked this genotype with mood disorders, suggesting that there may be a common pathway to blood flow problems in both the brain and the heart through which depression increases mortality in the elderly.
Other risk factors for vascular depression include diabetes, hypertension, and atherosclerosis. Those that had cardiac surgery are also at much higher risk.
There is also a growing body of evidence that recovery from heart attack and stroke is influenced by depression. Researchers point out that the heart is not only a pump that delivers blood to all vital organs, but it is also a sense organ that responds to emotional upset.
Disability and loss of stamina following a heart attack is often accompanied by a major depression. The emotional impact of this type of traumatic event brings the person face-to-face with his own mortality, and often suggests to him that he is much more vulnerable than he once believed. This revelation is often accompanied by bouts of hopelessness, anxiety, and depression. This type of reaction can be dangerous in that it can impede physical rehabilitation compliance with treatment.
Depression in the elderly can be expensive and lethal. Medical costs are 47 to 51 percent higher in depressed elders compared with non-depressed cohorts, and depressed elders have a 50 percent higher risk of heart attack than those free of depression.
Behavior, Memory and Cognition
Depression is also one of the most common under-diagnosed causes of memory problems. Depression has a profound effect on the ability to think, reason, and remember. In fact, the symptoms of depression can be so severe that it is often difficult to tell whether a person is suffering from depression or dementia. Because of this, several diagnostic tests have been developed to ferret out the differences between these two memory-destroying disorders.
It is vitally important that all elderly people be screened for depression because depression in cognitively intact individuals can mimic the signs of dementia, while depression in people with cognitive problems can make their problems worse.
Depressed people become focused on internal events. These may be memories about tragic losses, or about real and imagined transgressions. As just mentioned, the focus is often on physical symptoms such as body aches and pains. This internal preoccupation prevents the person from attending to the outside world.
Depression actually slows down the level of brain activity in the afflicted person, so that memory and thought-processing are impaired. People suffering from depression often are said to exhibit poverty of thought, which is the inability to process thought at all.
Depression is often one of the first signs of thyroid disease. Even subtle decreases in thyroid hormone can induce depression, and in the elderly, depression may be the only sign of thyroid dysfunction. For this reason, depressed residents should be routinely screened for thyroid problems, particularly if they complain of depression and fatigue.
Like the thyroid gland, dysfunction of the adrenal gland has been associated with depression, so adrenal function should also be checked.
Temporal lobe tumors are particularly inclined to cause depression, and are frequently masked by the psychological symptoms of headache and paresthesias.
Depression can also be caused by allergies to environmental toxins. For example, solvents like those used in paints, furniture-making, carpet- manufacturing, and boat-building have been reported to cause depression, confusion, and memory loss in many people.
Although rare, another potential cause is chronic exposure to heavy metals. Because elderly people may have an impaired ability to eliminate toxins from the body, these factors should be ruled out before further intervention.
Chemical causes of Depression
Although depression is often triggered by a loss or trauma, or a biochemical imbalance in the brain, it can also be caused by nutritional deficiencies or excesses; prescription, over-the-counter, and illegal drugs; alcohol, caffeine, and nicotine; hypoglycemia; and hormonal imbalances. In fact, research suggests that almost any chronic biochemical imbalance can cause depression.
Many medications, used alone or in combinations, may cause depressions. Often, reducing the dosages, elimination of use, or changing certain combinations will correct the problem. Here are a few of the most common culprits:
Anti-emetic drugs are used to prevent nausea. But if they are used in large doses or over a period of time, they may cause depression. If this is the cause, discontinuing the drug or using a smaller dose usually reverses the symptoms in two weeks.
Unfortunately, sedative drugs are often used by elderly people to promote sleep and reduce anxiety. Instead, they often lead to addiction, abuse, and an increased risk of depression and suicide. Because of this problem, some states now use computer tracking to see if the person is obtaining these medications from more than one doctor.
Steroid drugs, used as anti-inflammatories, often cause depression, which usually occurs late rather than early in their use.
Blood pressure medications can also cause depression and subsequent behavioral problems. Even though this is common knowledge, many doctors are unaware of how often people suffer from drug-induced depression, and fail to connect depressive symptoms with the medication.
Harvard researcher Dr. Jerry Avorn and his colleagues looked at how often antidepressants were prescribed to people taking beta-blockers such as Inderal, Lopressor, and Corgard. Examining the medical records of 143,253 residents, they found that 23 percent (almost one out of four) of those taking beta-blockers were also taking antidepressants.
This study revealed that doctors often give patients additional prescriptions to overcome side effects of another medication without realizing that the problems could actually be solved by eliminating the first medication.
Ingestion of large amounts of bicarbonate may lead to depressive symptoms. In addition, the vomiting of gastric acid and respiratory acidosis cause a rise in the plasma bicarbonate level. Many patients who have anxiety or hysteric vomiting attacks take over–the-counter bicarbonate as a relief, which eventually upsets blood chemistry and pushes them into depression.
Systemic antacids such as Tagamet and Zantac have high side effect profiles in older people. They have been known to cause depression, anxiety, and even psychosis in some individuals.
Although they are usually easy to diagnose, strokes – with or without physical impairment or disability – often cause depression. Strokes may be major or minor, and minor ones may produce as severe a depression as a major stroke.
The most effective treatment for post-stroke depression is antidepressant drug therapy.
Other contributing factors to depression can be physical problems such as hearing loss, vision problems, foot problems, and even dental problems.
I was once called for a consultation for a patient who had been isolating, refusing to leave her room, and refusing to participate in groups or mealtime. Although this woman had a history of depression, during the interview she told me, “I’m not leaving this room until I get my new dentures. I look so ugly without my teeth.” In this case, a dental consultation cured the problem.
The term psychotic depression was quite common prior to the 1940's. In fact, during that time, as many as two-thirds of hospitalized depressed patients were diagnosed as psychotically depressed. Today, the term has fallen out of favor, and less than ten percent of depressed patients are considered psychotic.
Nevertheless, psychotic depression happens frequently in the elderly. This type of depression often mimics dementia, and can include hallucinations, delusions, and other bizarre symptoms. It’s important to remember that depression alone can cause psychotic symptoms. When a person becomes delusional or begins to hallucinate, depression could be the cause.
About two-thirds of psychotically depressed people have delusions but no hallucinations, and about one-quarter hallucinate without delusions. Although delusions and hallucinations take many forms, patients often claim that their insides are rotting, and that the devil is speaking to them.
The most common delusion seen in psychotically depressed people is the delusion of persecution – the belief that other people are wishing the person harm. Often, the person feels that they deserve to be punished. Some say that they are evil and that God is punishing them. Elderly patients who express intense feelings of guilt and remorse should always be screened for psychotic symptoms.
The sudden onset of an anxiety disorder is unusual in elderly people, but many have had a long-standing history of anxiety disorders. When anxiety does appear late in life, it’s usually associated with a stressor, is a sign of medical illness, or may be a medication problem. These factors should always be assessed and ruled out before a diagnosis is made.
The root of anxiety is a malfunction of our innate fear response system. Fear is a normal human emotion. Although no one enjoys the feeling of fear, it has an important function – to help us avoid danger. For example, it’s normal to be afraid of something we have never encountered before. Fear prompts us to proceed with caution when we enter unexplored territory, and only when we feel that we can handle a situation does the fear disappear.
Fear has another important function – it promotes social bonding. All children are naturally afraid to be alone. Because children cannot survive without their parents, fear saves their life. A child who had no fear would wander off, and probably die.
Children instinctively run to their parents whenever they get scared, and the parent's natural tendency is to calm the child and allay the fear. Over time, this sequence of events teaches us how to cope. As we hear our mother’s voice say, “It’s all right, nothing will hurt you now,” over and over, we eventually make these words a part of ourselves. This process of being held and internalizing calming messages is called self-soothing.
So, if we spend most of our early years physically and emotionally attached to our mothers, as we grow and mature and learn to self-soothe, we are able to tolerate more and more time alone. We also come to realize that many of the things we fear will never happen – there are no monsters in the closet.
In the elderly, anxiety disorders can occur because of the failure of one or both of these factors – people with anxiety disorders are afraid to be alone and/or they have difficulty self-soothing.
There is evidence that this process of bonding with parents stabilizes the brain circuitry that mediates fear. In animal studies, it has been shown that animals that are handled and held regularly have a stable HPA axis (the circuit of the hypothalamus, pituitary and adrenal glands are part of out fight, flight, or freeze system).
Animals handled in infancy have increased hippocampal activity throughout their lifespan, and do not show HPA abnormalities in later life. Furthermore, their levels of cortisol are permanently lower, and this decreases the risk of dementia. In studies of older humans, HPA axis abnormalities are related to anxiety. These subjects have been found to consume higher levels of dietary fat and sugar – both risk factors for cognitive problems. They also have higher levels of plasma cortisol and a smaller number of cells in the hippocampus, the part of the brain that stores memory. These findings suggest a link between cortisol, anxiety, and increased risk for dementia
Although social bonding is a primary element in reducing fear, many elders have lost most of their social contacts – through death, illness, or relocation. Loss of social support provokes fear, and pain from the losses they have suffered makes them reluctant to form new friendships, which leads to isolation and increased anxiety.
Our alarm circuits prepare us for threats by increasing heart rate, blood pressure, and muscle tension. When this system becomes activated, we scan the environment for danger. Once the danger is identified, we make decisions on how to deal with it, and our alarm system returns to baseline.
But when the system itself goes awry, a person may experience a diffuse, global feeling of threat, and will assess the environment for danger, seeing nothing external that can be identified as a threat. Because the system is malfunctioning, the level of arousal does not return to baseline and the person begins to seek sources for their disease.
An anxious person becomes fixated on threats. Increased threat assessment means that the person’s working memory is occupied with danger, leaving no room for solutions. Lack of ability to generate solutions leaves a person frozen in indecision.
For these reasons, many anxious people focus only on reducing their feelings of anxiety, and not on recognizing and reducing the causes. Common methods of reducing anxiety are isolating and substance abuse, which cause more problems than they cure. Treatment must therefore focus on reducing threats, increasing coping skills, and helping with problem-solving.
Anxious people may also have another deficit – they cannot separate realistic fears from irrational fears. This means spending time perseverating over things that might happen, and whipping themselves into a frenzy. This type of behavior is more prevalent in older people who have low life-satisfaction, high levels of neuroticism, and who have not accomplished what they wished to in life.
Because older people suffer from many medical problems, including aches, pains, and gastrointestinal disturbances, they may conclude that these symptoms are the threat, and become preoccupied with them. This condition is called hypochondria, and this is one reason why older people are high medical users. Unfortunately, being labeled a hypochondriac means not being screened for anxiety, and effective intervention will not occur.
This can manifest itself by the person becoming overly-dependent on others and engaging in incessant attention seeking. They may also become overly-demanding and complaining. This type of behavior is often charted in care facilities as attention-seeking, and the diagnosis of anxiety is frequently missed.
Older women are twice as likely to have an anxiety disorder as older men are, and older adults are more likely to experience depressive symptoms along with anxiety.
Generalized anxiety disorder is the most common problem found in the elderly (followed by anxiety due to a general medical condition), affecting up to one- third of older adults. Often triggered by worry and increased threat assessment, this type of anxiety is also, in part, reality-based – older people have more to fear.
As well as being more prone to illness or injury, older people are also frequent victims of crime. Lack of mobility, decreased stamina, and waning strength contribute to feelings of vulnerability. An older person walking alone is a target for predators, and many people, rather than exploring ways to stay safe, become fearful of leaving their home. Although phobias are less common in this age group, agoraphobia is quite prevalent.
Stressors such as retirement, disability, money problems, alienation, widowhood, and loneliness may also increase anxiety. Any chronic illness (especially Parkinson’s, chronic obstructive pulmonary disease, and chronic pain) can contribute to feelings of anxiety.
Unfortunately, because many of these symptoms are common in older people, they are written off as components of normal aging rather than symptoms of anxiety. For these reasons, anxiety may be present in many elders, but interpreted as part of another problem, rather than the existence of a disorder. Some of these symptoms could also be interpreted as signs of dementia. Anxiety also presents as a component of depression in the elderly – 75 percent of general anxiety patients also fit the criteria for depression.
Panic disorders are rare in the older population. When panic disorders do appear, they are usually tied to a stressor such as a loss or an illness. Unfortunately, many elders who have experienced a panic attack are given tranquilizing drugs, which are not effective, are addictive, and greatly increase the risk of falls.
In an elderly person, it is important to distinguish depression from grief and sadness. Sadness is a transitory state, and very often is the result of revisiting a painful memory. Temporary bouts of sadness are common in older people, as most of them have had multiple wounds, regrets, and losses – and from time-to-time – revisit them. In these times, refocusing, reframing, or assistance in working though these events can ameliorate bouts of dejection. But while sadness may be a fleeting feeling, grief is a process that may last for months or years.
Grief is the process of mourning a significant loss. Most elderly people, especially those in long-term care facilities, have undergone multiple significant losses, such as the loss of spouse, loss of their home, loss of friends, and most importantly, the loss of their independence. These losses are monumental and should be grieved, but seldom are.
Instead, losses are minimized – that is, caregivers rather than addressing the problem, tell the person to “Cheer up.” While this is often said in an effort to comfort the person, it actually discounts and trivializes the loss. It is also not useful to tell a grieving person, “I understand how you must feel.” Unless you have actually suffered a similar loss, you don’t know how they feel.
You can never measure the extent of another person’s attachment or loss, and no loss is trivial. For example:
Mrs. Peterson was brought to the hospital because she was losing weight, was isolating, and was suffering frequent bouts of crying. She had told others that she wanted to die. It was discovered at the intake interview that she had recently lost her parakeet – her closest companion for the last ten years. No one had recognized the enormity of her loss. In fact, the board-and-care administrator had stated, “I wish she would quit crying about that stupid bird.” When this loss was validated and acknowledged, she was allowed to work it through, and eventually recovered.
We all recognize that loss has a significant impact on mood, but what is less attended to is the fact that loss also disrupts fundamental patterns of living. For example, Mrs. Johnson, who has recently lost her husband, has spent forty years with him. During this time she has developed, and stored, thousands of patterns of behavior. These programs allowed her and Mr. Johnson to accomplish the tasks of daily living. The patterns ranged from mundane routines such as going grocery shopping and cleaning the house, to more profound patterns such as solving problems together, coping with the challenges of life, and interchanges of intimacy.
The loss of Mr. Johnson is catastrophic, and requires grieving, but it also means the loss of dozens of patterns of behavior. Loss of patterns means immobilization and isolation – two events that can completely disable Mrs. Johnson. So, while grief work is the fundamental task of recovery from loss, learning new patterns is essential for reentry into the world.
Recently a pilot program that addresses this problem was conducted at the University of Washington School Of Medicine in Seattle by Dr. Paul Ciechanowski and associates. Called PEARLS (Program to Encourage Active, Rewarding Lives for Seniors), this was a community outreach intervention that helped seniors integrate patterns.
Ciechanowski evaluated the effectiveness of this home-based program in a group of 138 mostly homebound seniors (average age 73) who had been diagnosed with minor depression or dysthymia. Seventy-two percent of the study’s participants were referred by social agencies, and 28 percent were self-referred. Seventy-two percent lived alone, 42 percent belonged to an ethnic minority group, and 36 percent received antidepressant medications at baseline.
Over a period of 19 weeks, participants in the program received an average of 6.6 visits from social workers. The substance of the visits was a combination of problem-solving therapy, and a focus on the patients regularly becoming physically active and increasing behavior patterns outside of the home. PEARLS recipients who completed this program showed a 50 percent improvement in depression scores or complete remission by the end of 12 months. They also had fewer hospitalizations than the control group. The improvements in the participants not only restored their quality of life, but significantly decreased caregiver burden. Beside the program’s high degree of success in regard to establishing connections to the world, the most important element of this program was its cost – $630 per patient.
Another anxiety disorder that is under-diagnosed in this population is Post-Traumatic Stress Disorder. Older people often face catastrophic losses, hospitalizations, surgeries, heart attacks, and strokes, all of which can result in traumatization.
Grief is the negative emotional process experienced when at least one of a person’s most important relationships is ended unwillingly, through death, divorce, natural disasters, or relocation. Unfortunately, most elderly people have experienced multiple losses. Normally, grief is a time-limited reaction, but sometimes grief reactions become chronic and interfere with long-term functioning. This type of problem is called pathological grief.
Grief can have an immediate or delayed onset. Delayed onset occurs when the person gets stuck in the stage of denial. Delayed grief reactions, therefore, are somewhat similar to the symptoms of Post-Traumatic Stress Disorder, and should be considered an anxiety disorder. Pathological grief differs from normal grief in the development of anxious apprehension, phobias, panic, and depression.
Most societies have mourning rituals and ceremonies that surround the death or loss of a close member of the family. These rituals create a context in which all the bereaved relatives and friends can experience their painful emotions and work through their loss. However, these rituals and ceremonies no longer exist in much of American culture, and because of this, it's difficult or impossible for most people to do proper grief work.
Because of the loss of formal ritual, many people in our culture are actually unaware that they must mourn or grieve. Instead, they try to escape from their pain and carry on as usual. When this occurs, the buried feelings may erupt later, disguised in some other form – often in the form of panic attacks and anxiety symptoms.
The human grief response has its origins early in mankind's social evolution. For example, crying is an important survival mechanism. A small child separated from the tribe could be found by listening to his cries. The children that cried the most were the ones that were found the easiest. After thousands of years of development and evolution, crying when faced with loss has become a fundamental human instinct.
To help work through loss, traditional mourning rituals in other cultures encourage loud and sustained crying and the expression of painful emotions. After a few days of this, emotional exhaustion is experienced; it then becomes possible for the bereaved person to complete the emotional and cognitive aspects of the grieving process
Failure to mourn often results in suppression of the anger, the fear, and the related emotions in the grief process. Because these emotions never get expressed, the levels of arousal in the person remain persistently high. After the loss, the bereaved person may carry on with his usual daily activities. However, even though a grieving person may have successfully suppressed his grief, his body is still experiencing the grief reaction.
Symptoms may not appear until many years after the loss. When they do appear, it is frequently on or around the anniversary of the loss. The most common symptoms are panic attacks and phobias.
On occasion, the loss of one's health can becomes a substitute for the loss of the person. Instead of grieving, the person becomes preoccupied with phobias, panic attacks, or illness. The search for the cure for the illness unconsciously represents a search for the lost relative. Feelings of anger and rage are then displaced onto the doctors and caregivers who fail to find a cure.
Even if it is suggested that the anxiety disorder is a result of unresolved grief, the patient is very reluctant to engage in grief work. To make things even more difficult, the spouse or family members may ridicule the idea of grief work, claiming it is irrelevant to the problem. If the patient does begin grief work, family will often interfere with the process and ridicule her for weeping and crying. If this occurs, the treatment must be explained thoroughly to family members, and the family must be involved in the treatment process.
Suicide is currently the seventh leading cause of death in the United States. It accounts for over 24,000 deaths each year. Moreover, the suicide rate rises consistently as age increases – taking one’s own life is presently the ninth leading cause of death in the elderly. Although older Americans comprise 13 percent of the population, they account for 18 percent of all suicides. White males over 65 have the highest suicide rate – twice the rate of the general population, and six times the rate in women over 65.
Elderly people actually have a lower incidence of suicide attempts than younger people do, but they are much more intent on killing themselves, and therefore they have a much higher success rate. Nonfatal suicidal gestures are uncommon among the elderly. Unlike attempts by teens and borderlines, suicide attempts in the elderly are rarely done for social manipulation – they are the direct intent to die. Lethal methods tend to be used, and failure to kill one’s self is most often due to poor planning, rather than any lack of intent.
Someone age 65 or over completes suicide every 90 minutes – that’s 16 deaths a day. Nevertheless, suicide is uncommon in healthy elders. Most people find an increase in life satisfaction as they age.
However, suicide is high in the elderly medically ill population. Disease burden is a predictor of anxiety, depression, and suicide in this population.
One of the myths of suicide is that those who decide to kill themselves do not seek help before their attempt. Actually, over 60 percent of those who do commit suicide tell others beforehand. The typical suicidal person will tell at least three people about his intent before he attempts it.
Unfortunately, elderly suicidal people seldom seek help from mental health practitioners. The sufferer will most likely seek medical rather than psychological help. Studies on elder suicide show that more than 65 percent of all victims seek medical attention within three months before their suicides. Seventy-five percent have contacted their primary care physician within one month before their death, and over one-third have seen a doctor a week before their demise.
In fact, suicidal people almost always communicate their intent to kill themselves, and do it several times and in different ways. Communication may consist of overt statements of suicide, statements of not wanting to live, or statements that life is no longer worth living. Less direct methods of communication include making a will under unusual circumstances, changing insurance policies, giving away valued objects, or making statements of “putting my affairs in order.”
Having suicidal thoughts is not a normal phase of life. A suicidal person has a distorted view of reality, convinced that there are no solutions and that things will never change. Because of this, suicide has often been called a permanent solution to a temporary problem. It is, in fact, a maladaptive means to escape from anguish.
Major depression is the most common reason for suicide – the suicide rate among the depressed being four times higher than the national average. When the person is suffering from psychotic depression, the rate is five times higher.
Any psychotic disorder increases risk – there are not many old schizophrenics. A psychotic person who has paranoid thoughts, is inappropriately fearful, and is subject to panic states is at very high risk for self-harm. This risk is increased even more if the person hears voices commanding him to kill himself.
Suicide is more common in the divorced and widowed. Elderly men who lose their wives are at highest risk. Oftentimes, the wife was responsible for social activities of the couple, and her death or departure means an abrupt end of social interaction.
The more closely a person is involved with others, the lower the probability of suicide. Therefore, it is important to look at the person’s social support network when doing a suicide assessment. If the person has no friends or family, they are at high risk.
There is also a direct relationship between social status and suicide. In general, the higher one is on the socioeconomic ladder, the more likely she is to attempt suicide. For example, physicians and dentists have a much higher incidence of suicide than the general population.
Weakening of higher brain functions by sleeplessness, alcohol, or drugs also strongly contributes to the potential for self-destruction. In fact, half of all suicides are associated with alcohol abuse, and the suicide rate among elderly alcoholics is ten times that of those who do not drink. About 70 percent of successful suicides in the elderly are committed by persons with a previous diagnosis of alcoholism, psychosis, or organic brain syndrome.
The incidence of suicide also rises after surgery, particularly in surgeries that mutilate or change a person’s appearance; the impact on the person’s body image is often intolerable. This loss must be grieved completely in order for the person to move ahead.
Suicide by a close family member increases one's suicide potential significantly. Guilt, especially over the dead relative, feelings of worthlessness, the wish for punishment, social withdrawal, and feelings of hopelessness, anxiety, and agitation are all contributing factors.
However, the most important predictor of suicide is a previous attempt. Over half of those who commit suicide have had at least one previous attempt.
Silent suicide is the intent to kill one’s self by nonviolent means, often through self-starvation and resistance to care. These attempts to end one’s life often go unrecognized because the depression is not diagnosed, and resistance to care is seen as a bothersome behavioral problem rather than a suicide attempt. Because of this, resistance to care and noncompliance with treatment should always be considered as a sign of depression and suicidal intent.
Since more than half of all suicides occur in people suffering from mood disorders, one might expect that the implementation of the more effective SSRIs would decrease the suicide rate. Yet this has not happened. Psychological autopsy studies show that among depressed adults who have killed themselves, less than one-third of them were taking antidepressants at the time of their death. It is clear that in most cases, the diagnosis has been missed.
A study funded by the National Institute of Mental Health (NIMH) and conducted by Dr. Martha Bruce and colleagues at Cornell University, addressed the problem of missing diagnoses of depression and suicide in older patients. The pilot program took place in three major Eastern US cities, and was published in the March 3, 2004 Journal of the American Medical Association.
Reynolds and colleagues set out to demonstrate that by educating physicians and improving treatment up to guideline standards, a social worker, nurse or masters-level psychologist can significantly improve clinical outcomes.
Called PROSPECT (Prevention of Suicide in Primary care Elderly: Collaborative Trial), the program placed depression care managers in ten primary care practices located in Philadelphia, Pittsburgh and New York City. Each practice was paired with a similar practice without a depression care manger, which served as a control.
The care managers screened all patients visiting the clinics for depression and suicidality. Over two years, about 12 percent of the primary care patients tested positive for depression and suicidal ideation. From these, 598 (mostly females, two-thirds with major depression) were recruited into the study.
The care managers offered patients treatment for their depression including psychotherapy from the care manager and/or a serotonin selective reuptake inhibitor (SSRI) or another antidepressant, if clinically warranted. All treatment was supervised weekly by a psychiatrist. Care managers actively followed the patients, monitoring their symptoms, drug side effects, and treatment adherence.
The intervention did not lessen symptoms in patients with minor depression but it did significantly decrease suicidal thoughts. After eight months, 70 percent of patients with suicidal thoughts were symptom-free compared to controls. The results of this study show the importance of assessment of depression and suicidality in a primary care setting, and that treatment can significantly reduce the risk for suicide in late life.
As mentioned previously, the majority of older people who manifest symptoms of depression, anxiety, or suicide are high medical users, and visit their primary care physician frequently. While there, they may speak of multiple physical complaints. In these cases, the diagnosis of depression is often missed.
But even when they display clear signs of depression, there is a marked tendency for physicians to underestimate the severity of depressive symptoms, especially in patients who are more depressed. Studies show that doctors are most influenced by overt symptoms such as crying and depressed mood, which are valid – but not reliable – indicators of depression in this population. Anhedonia, guilt, suicidal thinking, and hopelessness are more potent indicators, but are seldom assessed and rarely spontaneously discussed by the patients. Missing these diagnoses not only precludes the opportunity for treatment, but also puts the patient in peril. Depression is associated with treatment refusal and poor treatment compliance even when there is a good medical prognosis. Those with anxiety often self-medicate with alcohol and sedatives, which increase the risk of further medical problems, including falls.
In 1999, Dr. Wayne J. Katon at the University of Washington in Seattle published an important paper addressing the barriers to effective treatment of mood disorders.
His research revealed that few patients diagnosed with depression and started on antidepressants received adequate dosage and duration of antidepressant therapy. In addition, about 40 percent of patients who started on antidepressants dropped out of treatment within one month.
Examining the results of this research, Katon concluded that acceptable outcomes in the treatment of depression were not occurring with traditional medical treatment (which usually consisted of brief, infrequent visits with a primary care physician). This led Katon to the idea of collaborative care. This type of care is done though a health care team, including mental health professionals and care managers who provide education, patient follow-up, and careful monitoring of outcomes. This type of model is particularly suited to the older population, who may have problems with travel, treatment compliance, and an aversion to mental health treatment.
Katon has also pointed out that treatment failure in this population is highest in elderly women, with only 37 percent of women showing significant improvement with treatment. Treatment failure was related to patients who had a low level of social support and low socioeconomic status, and showed high levels of neuroticism.
Treatment of depression and anxiety in the elderly
Ask all people being assessed about suicidal thoughts. Ask if the person has a plan. A plan and the means to carry it out are indicators of extremely high risk.
Get a thorough family history about depression and suicide from the person, family members, and friends, as this suggests a genetic predisposition. Studies show that suicide can have a genetic component, and low levels of serotonin are found in suicidal families. In these cases, SSRIs (such as Prozac) can be of great help.
Suicide is seen as the only solution to what appears to be an unsolvable problem. Effective intervention consists of helping the person identify the problem, and helping him explore constructive solutions.
Ask people with chronic pain about suicidal thoughts.
Chronic, unremitting pain often leads to the wish to die. However, when pressed, most people with chronic pain will agree that what they really want is to stop suffering. Once this is established, all efforts should be focused on reducing the pain. A good pain management program can do wonders in these cases.
Assess their social support network, and the activities of a typical day. A day spent with no friends and no joy is a day wasted. Help the person plan a day of enjoyment, and explore ways of connecting them with others who share similar interests.
If the person undergoing treatment for these disorders is cognitively intact, cognitive behavioral therapy is appropriate. The best outcomes in these cases result from a combination of therapy and antidepressant medication, keeping in mind that older people may be at more risk of side effects and drug interaction effects.
Re-integrate pleasant activities into the person’s daily regimen.
Grief is a normal response to loss. Sadness and depression are part of the grieving process, and should not be considered a mental disorder. Once the losses have been listed, explored, and discussed, some must be grieved. Through the loss assessment, you can explore losses that have not been grieved.
Most older people are not familiar with the process of grieving. One of the most effective ways to help them grieve is to explain the normal stages of grief. This normalizes the emotions they are feeling, and allows them to take the time to work through and resolve the grief.
Once a person has done this, have him engage in one of the activities. When he is finished, have him rate how much he actually enjoyed the activity. Depressed people under-rate their capacity for enjoyment. When they realize that they can actually enjoy the things they once did, they become more willing to do them again.
Tie current problems and stressors to the life review, and help him see that the skills and strengths he accumulated can be used to solve his current problems. Once you have found his favorite music, it can be an effective tool to refocus him and brighten his mood.
The following components of treatment are useful in treating depression and suicidality.
Construct a loss history
When a older adults appear to be depressed or anxious, a loss history can be useful. This is a historical survey of the person’s recent and remote losses. Losses can include the death of loved ones, but also can be the loss of a job, a pet, loss of a body part, loss of senses, or social standing. Inquire about child abuse, trauma, spousal abuse, and elder abuse, all of which may contribute to problems.
With a comprehensive loss and abuse history, you will have an outline of the person’s pain and sorrow.
Begin a life review
Life review should focus on the person’s triumphs, successes, and high points in her life. These strength and successes can then be linked to current concerns, which will increase coping skills.
With a life review, you will have a history of the person’s strengths.
Help the person list their talents and skills
Help the person construct a list of her positive qualities, talents, and skills. If she cannot do this, gather information about triumphs.
With a list of positive qualities, you will have a history of the person’s worth.
Construct a favorites list
This is a list of all the activities she used to enjoy. This can be done by using a favorites questionnaire. Ask about favorite activities, books, movies, foods, and music.
With this list, you will have a history of the person’s joy.
Use music for recollection
Playing music, especially favorite songs, can be a powerful trigger for recollection, which is a great help in gathering data for the categories listed above. Targeting songs from different times in a person’s lifespan will help them with the loss history, life review, favorites, and strengths and abilities. A familiar song can transport her back to moments in her life she had not thought of for years.
With music, you will have a history of the person’s heart.
In most cases, there is a medical origin of depression and anxiety. A thorough medical workup can reveal suspected causes. Therefore, a referral to a competent physician is the first step in treatment-planning. Keep in mind that less than 10 percent of physicians in this country are educated in geriatric medicine and aware of the medical problems listed above. For this reason, it is useful to provide them with some research papers delineating the medical causes of mood disorders. This will help them target their observations and clinical tests.
Once medical causes have been ruled out, and psychotherapeutic interventions have not been successful, depressed patients may improve with antidepressants. This success rate in older depressed people taking SSRIs is about 65 percent.
Medication for anxiety should be considered only when all other interventions have failed. Tranquilizers are not recommended for long-term use in the elderly because of their potential for abuse (they are addictive) and because they exacerbate cognitive problems. They also have psychomotor effects that lead to falls, which can be lethal. Despite these dangers, anti -anxiety drugs are the most common treatment modality for this population.
Older adults present with a vast array of behavioral and psychological symptoms. An assessment of the older adult must address the realms of mental symptoms, medical problems, and cognitive status
Because of the high likelihood that an older person will be suffering from multiple physical maladies that could impact mental status, a comprehensive assessment must include a thorough examination of all medical symptoms and all medications. Find out when the last physical was done, and get the results. Be aware that physicals may not include gastric assessments and immune deficits – common problems in this population. (See the sections above for the most common medical problems and their contribution to psychological problems.)
A medical history should be the first step in any diagnosis. It should include a history of all illnesses, injuries, and hospitalizations throughout the person’s lifespan. Unfortunately, this is often impossible, as medical records are lost and family members are unavailable. Often, the only data available is from the person himself, and he may have forgotten many of his illnesses, injuries, and aliments.
To further complicate things, the signs and symptoms of many diseases are often less severe, non-specific, or not present in many elders. People suffering from these disorders may not be able to give you an accurate description of what they are experiencing. The best you might get form a person is that she feels tired or she is “not herself.”
In addition, cognitive impairment must be assessed. The person’s capacity to think and reason, make informed decisions, and remember what is being recommended in terms of treatment will determine the method of treatment rendered. For example, a person with impaired cognition and memory will not benefit from cognitive therapy, and a person with memory deficits will not be able to recall what has been recommended.
If you are working in a long-term care setting, an assessment can be daunting. You will often have no access to medical records. There will be no family or friends that can supply historical information and the person will not remember his medical history. Occasionally, there will be a discharge summary available describing the person’s most recent hospitalization. This helps, but often contains little history. A history and physical may also appear in the chart, but often times it will be illegible.
What you are left with is the person’s description of his symptoms and concerns, and information from the staff about observable emotional and behavioral problems. Often the person will claim to have no problems, so you are left with your own observations and those of the staff.
Once you have gathered this information, look on the face sheet in the person’s chart. This document will tell you the person’s age and birth date. Check this with the person’s recollection of their age and birthday. Also on this paper will be a list of medical and psychiatric diagnoses.
A typical face sheet might contain something like this:
There is a high probability that some of these diagnoses are incorrect (especially the diagnoses of dementia – one out of four is incorrect). They have been made by different clinicians at various facilities over a long period of time. Check with staff and other clinicians to see if these diagnoses are still valid; if they are not, have them updated.
Next, go to the physician’s orders sheet in the chart to see what medications the person is currently taking, and if any medications have recently been added or discontinued. See if behavioral or emotional symptoms coincide with medication changes.
Check the side effects of all medications to see if they could be contributing to the presenting problems. Alert those who are participating in treatment planning that some of the presenting problems may be due to side effects.
Also, check to see if the medications coincide with the medical and psychiatric diagnoses. The desired outcome would be that each diagnosis corresponds to a medication or treatment regimen. However, you may discover that there is no evidence that some of the diagnoses are being treated. If so, talk to everyone involved in care-planning about this discrepancy and take corrective action. You may also discover that the person is taking medication for which there is no diagnosis. Take corrective action here also. Ask the person if they are also taking any vitamins, herbs, or over-the-counter remedies, as these may also affect mood and behavior.
If you work in an outpatient setting, ask your patient or client to bring with them a bag containing all of the prescription medication, over-the-counter medication, vitamins, herbs, and supplements he is taking. Make a list of them and do some homework to see if any of these substances may have unintended side effects . A physician trained in geriatric medicine and consultant pharmacists can be invaluable in this part of an assessment, but in the real world, most of you will be on your own. [You can find a consultant pharmacist near you at https://www.ascp.com/find-senior-care-pharmacist.]
The next realm to explore is the impact of medical illness on mental difficulty, which could be causing the problems. Do some homework here also to see if the medical illnesses could be causing or contributing to the psychological symptoms you observe.
After this, ask the person to tell you everything she knows about her diagnoses. This will give you a feeling for her awareness, judgment, insight, and capacity to take an active part in her treatment.
The last area to assess is memory and cognition. Assessment instruments such as the Mini Mental Status Exam can give you a snapshot of potential problems. Asking questions about memory problems, historical data, and current events will give you an idea as to orientation and awareness.
Formal tests of memory and executive function can also be used, keeping in mind that, in general, older people do not like to be asked too many questions, do not like to be tested, and get anxious, frustrated, and irritated when they do not do well. Also, few of these tests have been normed for people over 80. For this reason, informal assessment is usually the best choice. Once you have ruled out medical illness, medication problems, and cognitive impairment as a cause of the presenting problem, you can make a diagnosis just as you would in a younger person.
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For data on the status of the long-term care industry go to the American Health Care Association http://www.ahca.org/
For information on long term care issues http://www.efmoody.com/longterm/longtermoverview.html
For information on magnesium, aging, and metal health, visit The Magnesium Web Site http://www.mgwater.com/lista.shtml
For information on not-for-profit nursing homes, continuing care retirement communities, assisted living and senior housing facilities, and home and community-based service providers, look at the American Association of Homes and Services for the Aging website http://www2.aahsa.org/
For information on substance abuse issues, visit Florida Alcohol and Drug Administration http://www.fadaa.org/resource/justfact/elderly.html
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