Mental health in later life - nursing paper help

Chapter 28

Mental Health

Mental health is not different in later life, but the level of challenge may be greater

Well-being in late life can be predicted by cognitive and affective functioning earlier in life

Mental health care for older adults lags behind that for other age groups, and mental disorders have not yet received adequate attention in global health

Globally, 5%-7% of older adults experience depression, 3.8% experience anxiety and approximately 1% have substance use issues

Mental Health

Many individuals in the baby boomer generation have experienced mental health consequences from military conflict, and the 20th century drug culture will add to the burden of psychiatric illness in the future

The most prevalent mental health problems later in life are anxiety, severe cognitive impairment, and mood disorders

Alcohol abuse and dependence is a growing concern

Healthy People 2020: Mental health and mental health disorders (older adults) (Healthy People 2020 A)

Healthy People 2020

Reduce Suicide Rate

Reduce proportion of pts with major depressive disorder

Increase primary care facilities providing mental health care on site/referral

Increase numbers who receive treatment for mental health disorders

Increase treatment that address concurrent diseases like substance abuse and other MH disorders

Increase depression screening

Increase treatment of homeless with MH disorders

Stress and Coping in Late Life

Stress and stressors

The experience of stress is an internal state accompanying threats to self

The narrowing range of bio-psychosocial homeostatic resilience and changing environmental needs as one ages may produce stress overload

Stress and Coping in Late Life

Effects of stress

Adults show greater immunological impairments associated with distress or depression

Older people often experience multiple simultaneous stressors (Box 28-2)

Any stressors that occur in the lives of older people may actually be experienced as a crisis if the event occurs abruptly, is unanticipated, or requires skills or resources the individual does not possess

Stress can result in worsening of already present chronic health conditions like CV disease and dementia

When we look at this age group, they may have more losses piled on top of one another (older people die more

Often than younger, so imagine losing a spouse, a child, a neighbor, experiencing an illness—no opportunity to rebound

Before getting clobbered again with another stressor!

Older adults tend to require more time to rebound from stress

Great difference between individuals, but anticipate the older adult may have more issues

Stress and Coping in Late Life

Factors affecting stress

Cognitive style, coping strategies, social resources, personal efficacy, and personality characteristics have all been found to be significant to stress management

Social relationships and social support are particularly salient to stress management and coping

Factors influencing ability to manage stress (Box 28-3)

Health and fitness

Sense of control over events

Self awareness

Patience and tolerance

Coping skills

Resilence

Hardiness

Resourcefulness

Social support

Strong sense of self

Stress and Coping in Late Life

Factors affecting stress

Coping

Coping strategies

Identification

Coordination

Appropriate use of personal and environmental resources

How does the person view the current stress?

Do they see it as a threat?

What tools do they have to address it?

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

General issues in the psychosocial assessment involve distinguishing among normal, idiosyncratic, and diverse characteristics of aging and pathological conditions

Includes examination for cognitive function and conditions of anxiety and adjustment reactions, depression, paranoia, substance use, depression, and suicidal risk

Obtaining assessment data from elders is best done during short sessions after some rapport has been established

Understanding of past and present history is useful for understanding the patient’s current reactions to what is occurring

Sometimes it is impossible to get the information needed to fully understand how a person will or is reacting to an issue

Think about how your younger years, including childhood and young adult years have impacted how you cope or feel about

Things that happen in your life—it will affect your patient in a similar manner, so try to get a picture of past experiences

Great time to try to get a “life story”

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Enhancing functional status and independence, promoting a sense of control, fostering social supports and relationships, and connecting to resources are all important nursing interventions to enhance coping ability

Meditation, yoga, HeartMath, mindfulness, exercise, spirituality, and religiosity can enhance coping ability

Mind-body therapies are most helpful

Reminiscence is useful in understanding coping style

Factors Influencing Mental Health

Stigma

Ageism

Attitudes and beliefs

According to WHO, 15% of adults age 60 and older have a mental disorder (frequently untreated)

Reasons include

reluctance on the part of older people to seek help because of pride of independence

stoic acceptance of difficulty

unawareness of resources

lack of geriatric mental health professionals and services

lack of adequate insurance coverage

May be looked at as a normal consequence of aging or blamed on dementia

Factors Influencing Mental Health

Geropsychiatric nursing

A master’s level subspecialty within the adult-psychiatric mental health nursing field

The Geropsychiatric nursing initiative has developed geropsychiatric nursing competency enhancements for entry- and advanced practice–level education

Factors Influencing Mental Health

Culture and mental heealth

What may be defined as mental illness in one culture may be viewed as normal in another

Cultural variations in expressing mental distress (Box 28-4)

Disparities in mental health service use by racial and ethnic minority groups are well documented

Sexual minority individuals, particularly older gay men, demonstrate higher rates of mental disorders, substance abuse, suicidal ideation, and deliberate self-harm than heterosexual populations

Factors Influencing Mental Health

Culture and mental health

The newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has an increased emphasis on culture and mental health, including the range of psychopathology across the globe

Cultural components of DSM-5 (Box 28-5)

Components of cultural formulation interview in DSM-5 (Box 28-6)

Cultural assessment (Box 28-7)

Factors Influencing Mental Health

Availability of mental health care

Dedicated financing for older adult mental health is limited, even though about 20% of Medicare beneficiaries experience some mental disorder each year

Medicare spends five times more on beneficiaries with severe mental illness and substance abuse disorders than on similar beneficiaries without these disorders

The CMS health risk assessment and annual wellness visit for Medicare beneficiaries includes screening for depression, questions on alcohol consumption, and detection of cognitive impairment

Factors Influencing Mental Health

Settings of care

Older people receive psychiatric services across a wide range of settings, including acute and long-term inpatient psychiatric units, primary care, and community and institutional settings

The majority receive care from primary care providers

It is critical to integrate mental health and substance abuse with other health services including primary care, specialty care, home health care, and residential- and community-based care

Factors Influencing Mental Health

Nursing homes and assisted living

Nursing homes, and increasingly residential care/assisted living facilities, although not licensed, are providing the majority of care given to older adults with psychiatric conditions

Obstacles to care in these settings:

Shortage of trained personnel

Limited availability and access for psychiatric services

Lack of staff training related to mental health/illness

Inadequate Medicaid/Medicare reimbursement

New models of mental health care services are needed in these settings to address growing needs

Mental Health Disorders

Anxiety disorders

Unpleasant and unwarranted feelings of apprehension, which may be accompanied by physical symptoms

Becomes problematic when prolonged, exaggerated, and interferes with function

Mental Health Disorders

Prevalence and characteristics

17% of adults aged 65 and over experience a diagnosable anxiety disorder

The prevalence is higher among individuals with physical illnesses, particularly those in need of home health care or in live-in residential settings

Anxiety disorders are not considered part of the normal aging process

Late-life anxiety is often comorbid with major depressive disorder, cognitive decline and dementia, and substance abuse

Mental Health Disorders

Consequences of anxiety

Anxiety symptoms and disorders are associated with many negative consequences:

Increased hospitalizations

Decreased physical activity and functional status

Sleep disturbances

Increased health services use

Substance abuse

Decreased life satisfaction

Increased mortality

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

Nurses can identify anxiety-related symptoms and initiate assessments leading to appropriate treatment and management

Assessment focuses on:

Physical, social, and environmental factors.

Past life history.

Long-standing personality.

Coping skills.

Recent events.

Anxiety is a common side effect of drugs (Box 28-8)

Antihypertensives

Corticosteroids

Anticholinergics

Caffeine

Nicotine

Withdrawl form alcohol, sedatives

OTC appetite suppressants and cold preparations

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Depends on symptoms, specific anxiety diagnosis, comorbid medical conditions, and current medication regimen

Pharmacological

First line: selective serotonin reuptake inhibitors

Second line: short-acting benzodiazepines

Nonpharmacological

Cognitive behavioral therapy, exposure therapy, interpersonal therapy

Interventions for anxiety (Box 28-9)

Mental Health Disorders

Posttraumatic stress disorder (PTSD)

Originally considered an anxiety disorder, the DSM-5 has reclassified it in a new chapter, Trauma- and Stressor-Related Disorders, which covers acute stress disorders, adjustment disorders, and reactive attachment disorders

PTSD is a psychobiological mental disorder associated with changes in brain function and structure affecting survivors of combat, terrorist attacks, natural disasters, serious accidents, assault/abuse, sudden and major emotional losses

Mental Health Disorders

Prevalence

War veterans have high prevalence for PTSD

Older women with a history of rape or abuse as a child may also experience symptoms of PTSD when institutionalized, particularly during the provision of intimate bodily care activities, such as bathing

Clinical examples of PTSD in older adults (Box 28-10)

Interventions may need to be adjusted based on the reasons for the symptoms—review Box 28-10

How much PTSD is missed?

How can we adjust the environment to support the patient?

Mental Health Disorders

Symptoms

DSM-5 includes four major symptom clusters for diagnosis:

Reexperiencing

Avoidance

Persistent negative alterations in cognition and mood

Alterations in arousal and receptivity

Mental Health Disorders

Consequences

Depression is present in half of individuals with PTSD

Co-occurring PTSD and depression is associated with greater symptoms, reduced quality of life, and increased health care utilization

There may be association between PTSD and greater incidence and prevalence of dementia

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

Care of individuals with PTSD involves awareness that certain events may trigger inappropriate reactions, and patterns should be identified when possible

Knowing the person’s past history and life experiences is essential in understanding behavior and implementing appropriate interventions

Hartford Institute for Geriatric Nursing recommends the Impact of Event Scale-Revised (IES-R) (Box 28-1)

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Understanding of how to treat PTSD among older adults is still developing

Recommendations are that older adults can benefit from cognitive behavioral therapy and prolonged exposure therapy

Evidence-based psycho-spiritual interventions

Pharmacological therapy

Therapy should be individualized to meet specific concerns and needs of each unique patient, and may include individual, group, and family therapy

Mental Health Disorders

Schizophrenia

Prevalence

Older adults are the fastest growing segment of the total schizophrenic population, and the numbers are expected to grow with increased longevity of the population

Onset of schizophrenia after the age of 45 is identified as late-onset; and after the age of 60 the onset of schizophrenia is considered to be rare

Mental Health Disorders

Symptoms

Positive symptoms of delusions, hallucinations, disorganized speech, disorganized behavior

Negative symptoms of flat or blunted affect, anhedonia, avolition; and cognitive symptoms of poor executive functioning, and limited attention span

Mental Health Disorders

Consequences

Persons with schizophrenia have a life expectancy 15 years shorter than that of an unaffected person

Costly disease in terms of suffering and medical costs

The majority of older people with schizophrenia now reside in nursing homes

Usually due to decreased access to regular health care and interventions

Adverse effects related to medications used to treat schizophrenia

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Treatment includes both pharmacological and nonpharmacological

Other important interventions include a combination of support, education, physical activity, and cognitive-behavioral therapy

Psychotic Symptoms in Older Adults

Onset of true psychiatric disorders is low among older adults, but psychotic manifestations may occur as a secondary syndrome in a variety of disorders, the most common being neurocognitive disorders and Parkinson disease

Paranoid symptoms

Delusions

Hallucinations

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

The assessment dilemma is often one of determining if paranoia, delusions, and hallucinations are the result of medical illness, medications, dementia, psychoses, and sensory deprivation or overload because treatment will vary accordingly

Treatment must be based on comprehensive assessment

Assessment of vision and hearing is also important since these impairments may predispose the older person to paranoia or suspiciousness

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Frightening hallucinations or delusions arise in response to anxiety-provoking situations and are best managed by:

Reducing situational stress.

Being available to the person.

Providing a safe, nonjudgmental environment.

Attending to fears more than content of delusion or hallucination

Identify the client’s strengths and build on them

If symptoms interfere with function and safety, consider antipsychotics if other interventions don’t work

Mental Health Disorders

Bipolar disorder (BD)

DSM-5 defines BD as a recurrent mood disorder that includes periods of mania and/or hypomania or major depression (Bipolar 1) or major depression and hypomanic episodes (Bipolar II)

20% of older adults with BD experience their first episode after 50 years of age

With the aging population, predictions are there will be a drastic increase

BDs stabilize in later life, and individuals tend to have longer periods of depression

Frequently misdiagnosed, underdiagnosed, and undertreated

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

Thorough physical examination and laboratory and radiological testing to rule out physical causes of symptoms and identify comorbidities

Accurate individual and family history

Episodes of mania combined with depressed features and a family history of BD are highly indicative of the diagnosis

There is a strong hereditary component to BD (Box 28-13)

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Pharmacotherapy

Lithium

Antidepressants

Anticonvulsants

Psychosocial

Intensive psychotherapy

Cognitive behavior therapy

Interpersonal and rhythm therapy

Family-focused therapy

Mental Health Disorders

Depression

Not a normal part of aging, most older people are satisfied with their lives, despite physical problems

Important to understand the influence of late-life stressors and changes and beliefs of older people, society, and health professionals may have about depression and treatment

Mental Health Disorders

Prevalence

Depression remains underdiagnosed and undertreated in the older population

Depression is a leading cause of disease burden globally and is projected to increase

Prevalence rates of depression in older adults likely to double by 2050

Stigma associated with depression may be more prevalent in older people

Health professionals often expect older people to be depressed and may not take appropriate action to assess and treat depression

Mental Health Disorders

Consequences

Depression is a common and serious medical condition second only to heart disease in causing disability and harm to an individual’s health and quality of life

It is associated with negative consequences such as:

Delayed recovery from illness and surgery.

Excess use of health services

Cognitive impairment.

Exacerbation of co-existing medical illnesses.

Malnutrition.

Decreased quality of life.

Increased suicide and nonsuicide-related death.

Mental Health Disorders

Etiology

Causes of depression are complex and must be examined in a bio-psychosocial framework

Factors of health, gender, developmental needs, socioeconomics, environment, personality, losses, and functional decline are all significant to the development of depression in later life

Neurotransmitter imbalances have strong association with many depressive disorders

Medical disorders and medications can result in depressive symptoms (Boxes 28-14 and 28-15)

Common risk factors for depression (Box 28-16)

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

Older people who are depressed report more somatic complaints such as insomnia, loss of appetite and weight loss, memory loss, and chronic pain

Assessment of depression (Box 28-17)

Screening of all older adults for depression should be incorporated into routine health assessments across the continuum of care

Promoting Healthy Aging Implications for Gerontological Nursing

Interventions

The goals of depression treatment in older adults are to decrease symptoms, reduce relapse and recurrence, improve function and quality of life, and reduce mortality and health care costs

Nonpharmacological

Exercise (Box 28-19)

Integrated care

Pharmacological

Other treatments, such as electroconvulsive therapy (ECT) or Repetitive transcranial magnetic stimulation (rTMS)

Family and professional support (Box 28-19)

Mental Health Disorders

Suicide

The suicide rates for white males 85 years and older is high

Women in all countries have lower suicide rates

In most cases, depression and other mental health problems, including anxiety, contribute significantly to suicide risk

Possible contributing factors to rising suicide rates include the economic downturn, intentional overdoses associated with the increase in use of prescription opioids, other substance use, and a cohort effect based on the high suicide rates of this age-group in their adolescent years

Many older adults who die by suicide reached out for help before they took their own life

Suicide risk and recovery factors (Box 28-20)

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

The lethality potential of an elder must always be assessed when elements of depression, disease, and spousal loss are evident

Establish a trusting and respectful relationship with the person

Any direct, indirect, or enigmatic references to the ending of life must be taken seriously and discussed

The Columbia-Suicide Severity Rating Scale (C-SSRS) is an evidence-based suicide assessment tool used by many hospitals and organizations

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Have a suicide protocol in place if a positive response is obtained from any of the questions

The person should never be left alone for any period until help arrives to assist and care for the person

Patients at high risk should be hospitalized

Patients at moderate risk can be treated as outpatients provided they have adequate social support and no access to lethal means

Patients at low risk should have a full psychiatric evaluation and be followed carefully

Mental Health Disorders

Substance use disorders

Substance use disorders among older adults are a growing public health concern

Baby boomer generation has had more exposure to alcohol and illegal drugs in their youth and have a more lenient attitude about substance use

Psychoactive drugs are more readily available for dealing with anxiety, pain, and stress

Cocaine- and heroin-related admissions are on the rise in the older adult population and the incidence of opioid abuse and misuse is also increasing

Substance abuse objectives (Healthy People 2020 B)

Mental Health Disorders

Alcohol use disorder

Prevalence and characteristics

Alcohol use disorders are reported in 11% of adults aged 54-64 years and 6.7% of those older than 65

Alcoholism is the third most prevalent psychiatric disorder (after dementia and anxiety) among older men

Late-onset drinking may be related to situational events such as illness, retirement, or death of a spouse and includes a higher number of women

Two-thirds of elderly alcoholics are EOS drinkers (30-40 years of age)

Mental Health Disorders

Alcohol use disorder

Gender issues

Men are four times more likely to abuse alcohol

Women of all ages significantly more vulnerable to effects

Physiology

Older people develop higher blood alcohol levels because of changes of aging altering absorption/distribution

Consequences

Cirrhosis of the liver, cancer, immune disorders, cardiomyopathy, cerebral atrophy, dementia, delirium

Many drugs that elders use cause adverse effects when combined with alcohol (Box 28-22)

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

Reasons for the low rate of alcohol detection in older adults: poor symptom recognition, inadequate knowledge about screening instruments, lack of age-appropriate diagnostic criteria for abuse in older people, and ageism

Short Michigan Alcoholism Screening Test (Table 28-1)

Assessment of depression is important

Signs and symptoms of potential alcohol problems (Box 28-23)

Alcohol guidelines

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions

Treatment and intervention strategies:

Cognitive-behavioral approaches

Individual and group counseling

Medical and psychiatric approaches

Alcoholics Anonymous

Family therapy

Case management and community home care services

Formalized substance abuse treatment

Mental Health Disorders

Acute alcohol withdrawal

Withdrawal from alcohol can become a life-threatening emergency

Detoxification should be done in an inpatient setting

Symptoms of acute alcohol withdrawal vary but may be more severe and last longer in older people

Delirium tremens: alcohol withdrawal delirium

Clinical Institute Withdrawal Assessment scale is recommended as a valid and reliable screening instrument

Mental Health Disorders

Other substance abuse concerns

Misuse and abuse of prescription psychoactive medications

Dependence on sedative, hypnotic, or anxiolytic drugs

STAMP Out Prescription Drug Misuse and Abuse Toolkit

Question 1

Which condition is ranked as fourth leading cause of death for older adults?

Schizophrenia

Anxiety

Major depressive disorder

Suicide

ANS: D

Question 2

The goals of depression treatment in the older adult include which of the following?

Reduce mortality and health care costs.

Improve function and quality of life.

Reduce relapses and recurrence.

All of the above.

ANS: D