Theris A. Touhy
Mental health
THE LIVED EXPERIENCE
An older man wrote his philosophy succinctly:
“I have no ideas about what would constitute happiness for anyone else, considering the differences in taste and preferences, and no spate of ideas about improving the lot of the aged. But I am sure that among other things, a calm acceptance of the facts of life is a great help. I consider serenity and peace of mind two of the greatest gifts I have, although I cannot tell you where they come from or how to get them.”
(Burnside, 1975)
Learning objectives
Upon completion of this chapter, the reader will be able to:
• Discuss factors contributing to mental health and wellness in late life.
• Specify several indications of substance abuse in elders, and discuss appropriate nursing responses.
• Evaluate interventions aimed at promoting mental health and wellness in older adults.
Glossary
Hallucination A false sensory perception in the absence of a real stimulus (e.g., hearing voices that no one else can hear).
Illusion Misinterpretation of a real experience (e.g., thinking a curled rope is a snake).
evolve.elsevier.com/Ebersole/gerontological
Mental health
Mental health is not different in later life, but the level of challenge may be greater. Developmental transitions, life events, physical illness, cognitive impairment, and situations calling for psychic energy may interfere with mental health in older adults. These factors, though not unique to older adults, often influence adaptation. However, anyone who has survived 80 or so years has been exposed to many stressors and crises and has developed tremendous resistance. Most older people face life’s challenges with equanimity, good humor, and courage. It is our task to discover the strengths and adaptive mechanisms that will assist them to cope with the challenges.
Evans (2008) notes that most older adults manage the transitions and stresses that may accompany aging with “resilience, hardiness and resourcefulness but those with specific vulnerabilities may develop maladaptive responses and mental illness” (p. 2). Older adults who lack adequate social support or have accumulated stressors, unresolved grief, preexisting psychiatric illness, cognitive impairment, or inadequate coping resources are most vulnerable to mental health problems. Particularly at risk are older adults who have dual risk factors of life transition and loss of social support.
What it means to be mentally healthy is subject to many interpretations and familial and cultural influences (see Chapter 4). Mental health, as with physical health, can be thought of as being on a fluctuating continuum from wellness to illness. Mental health in late life is difficult to define because a lifetime of living results in many variations of personality, coping, and life patterns. One can say what 5-year-olds or 15-year-olds in general are like, but the same is not true for older people. Each individual becomes, the older he or she gets, more uniquely himself or herself.
Autonomy, intimacy, generativity, and integrity are all aspects of mentally healthy adult adaptation (Erikson et al., 1986) (see Chapter 6). Well-being in late life can be predicted by cognitive and affective functioning earlier in life. Thus, it is very important to know the older person’s past patterns and life history. Using Maslow’s Hierarchy of Needs model (see Chapter 1), the higher one rises in terms of needs met, the more likely one is to be emotionally healthy (self-actualization).
Qualls (2002) offered the following comprehensive definition of mental health in aging: A mentally healthy person is “one who accepts the aging self as an active being, engaging available strengths to compensate for weaknesses in order to create personal meaning, maintain maximum autonomy by mastering the environment, and sustain positive relationships with others” (p. 12).
Including older adults with dementia, nearly 20% of people older than 55 years of age experience mental health disorders that are not part of normal aging, and these figures are expected to rise significantly in the next 25 years with the aging of the population. “The long-term consequences of military conflict and the twentieth century drug culture will add to the burden of psychiatric illnesses” (Kolanowski & Piven, 2006). Prevalence of mental health disorders may be even higher because these disorders are both underreported and not well researched, especially among racially and culturally diverse older people. The numbers of older people with mental illness will soon overwhelm the mental health system.
Mental disorders are associated with increased use of health care resources and overall costs of care (Evans, 2008) and are the leading cause of disability in the United States and Canada (U.S. Department of Health and Human Services [USDHHS], 2012). Healthy People 2020 (USDHHS, 2012) includes mental health and mental health disorders as a topic area (see the Healthy People box).
HEALTHY PEOPLE 2020
Mental health and mental disorders (older adults)
From U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Healthy people 2020 (2012). Available at http://www.healthypeople.gov/2020.
The focus of this chapter is on the differing presentation of mental health disturbances that may occur in older adults, alcohol and substance abuse problems, and the nursing responses important in maintaining the mental health of older adults at the optimum of their capacity. Readers should refer to a comprehensive psychiatric–mental health text for more in-depth discussion of mental health disorders. A discussion of cognitive impairment and the behavioral symptoms that may accompany this disorder is found in Chapter 21.
Factors influencing mental health care
Attitudes and beliefs
The rate of utilization of mental health services for elders, even when available, is less than that of any other age group. Estimates are that 63% of older adults with a mental health disorder do not receive the services they need, and only about 3% report seeing mental and behavioral health professionals for treatment (American Psychological Association, 2012). Some of the reasons for this include reluctance on the part of older people to seek help because of pride of independence, stoic acceptance of difficulty, unawareness of resources, and fear of being “put away.” Stigma about having a mental health disorder (“being crazy”), particularly for older people, discourages many from seeking treatment. Ageism also affects identification and treatment of mental health disorders in older people.
Symptoms of mental health problems may be looked at as a normal consequence of aging or blamed on dementia by both older people and health care professionals. In older people, the presence of comorbid medical conditions complicates the recognition and diagnosis of mental health disorders. Also, the myth that older people do not respond well to treatment is still prevalent. Other factors—including the lack of knowledge on the part of health care professionals about mental health in late life; inadequate numbers of geropsychiatrists, geropsychologists, and geropsychiatric nurses; and limited availability of geropsychiatric services—present barriers to appropriate diagnosis and treatment.
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. Nurses will encounter older adults with mental health disorders in emergency departments or in general medical-surgical units. Admissions for medical problems are often exacerbated by depression, anxiety, cognitive impairment, substance abuse, or chronic mental illness. Medical patients present with psychiatric disorders in 25% to 33% of cases, although they are often unrecognized by primary care providers. Evans (2008) suggests that nurses who can identify mental health problems early and seek consultation and treatment will enhance timely recovery.
Nursing homes and, increasingly, residential care/assisted living facilities (RC/ALs), although not licensed as psychiatric facilities, are providing the majority of care given to older adults with psychiatric conditions. Estimates of the proportion of nursing home residents with a significant mental health disorder range from 65% to 91%, and only about 20% receive treatment from a mental health clinician (Grabowski et al., 2010). Nursing homes are also caring for younger individuals with mental illness, and the number of individuals with mental illness other than dementia has surpassed the number of dementia admissions (Splete, 2009). It is often difficult to find placement for an older adult with a mental health problem in these types of facilities, and few are structured to provide best practice care to individuals with mental illness. Older adults in home and community settings also experience mental health concerns and inadequate treatment.
Along a range of different measures of quality, the treatment of mental illness in nursing homes and residential care facilities is substandard (Grabowski et al., 2010). Some of the obstacles to mental health care in nursing homes and RC/AL facilities include (1) shortage of trained personnel; (2) limited availability and access for psychiatric services; (3) lack of staff training related to mental health and mental illness; and (4) inadequate Medicaid and Medicare reimbursement for mental health services. An insufficient number of trained personnel affects the quality of mental health care in nursing homes and often causes great stress for staff.
New models of mental health care and services are needed for nursing homes and RC/AL facilities to address the growing needs of older adults in these settings. Suggestions for optimal mental health services in nursing homes include the routine presence of qualified mental health clinicians; an interdisciplinary and multidimensional approach that addresses neuropsychiatric, medical, environmental, and staff issues; and innovative approaches to training and education with consultation and feedback on clinical practices (Grabowski et al., 2010). Training and education of frontline staff who provide basic care to residents is essential. There is an urgent need for well-designed controlled studies to examine mental health concerns in both nursing homes and RC/ALs and the effectiveness of mental health services in improving clinical outcomes.
Cultural and ethnic disparities
Lack of knowledge and awareness of cultural differences about the meaning of mental health, differences in the way concerns may become apparent, the lack of culturally sensitive instruments for measuring behavioral outcomes, the lack of culturally competent mental health treatment, and limited research in this area must all be addressed in light of the rapidly increasing numbers of culturally and ethnically diverse older adults (see Chapter 4) (Kolanowski & Piven, 2006). More data are needed on the mental health needs of geriatric and ethnic minority populations, and, in recognition of this need, a follow-up study to the Institute of Medicine’s study (IOM, 2008), Retooling for an Aging America: Building the Health Care Workforce, will be conducted.
Gerontological nurses must advocate for better and more appropriate treatment of mental health needs for older people and should closely monitor proposals for federal and state revisions to services and budget cuts in this area. Increased attention to the preparation of mental health professionals specializing in geriatric care is important to improve mental health care delivery to older adults (Mellilo et al., 2005). Geropsychiatric nursing is the master’s level subspecialty within the adult-psychiatric mental health nursing field. The Geropsychiatric Nursing Collaborative, a project of the American Academy of Nursing funded by the John A. Hartford Foundation, has developed geropsychiatric nursing competency enhancements for entry and advanced practice level education and will be developing a range of training materials and learning tools to improve the current knowledge and skills of nurses in mental health care for older adults (http://hartfordign.org/education/geropsych_nursing_comp/).
Mental health disorders
Anxiety disorders
A general definition of anxiety is unpleasant and unwarranted feelings of apprehension, which may be accompanied by physical symptoms. Anxiety itself is a normal human reaction and part of a fear response; it is rational, within reason. Anxiety becomes problematic when it is prolonged, is exaggerated, and interferes with function.
Anxiety disorders are not considered part of the normal aging process, but the changes and challenges that older adults often face (e.g., chronic illness, cognitive impairment, emotional losses) may contribute to the development of anxiety symptoms and disorders. Many anxious older people have had anxiety disorders earlier in their lives, but late-onset anxiety is not a rare phenomenon. Anxiety disorders that occur in older people include generalized anxiety disorder (GAD), phobic disorder, obsessive-compulsive disorder, panic disorder, and posttraumatic stress disorder (PTSD). Additionally, the high prevalence of comorbid mood-anxiety disorders suggests the importance of further investigation of the modifying influence of anxiety on depression treatment outcomes (Byers et al., 2010).
Prevalence
Epidemiological studies indicate that anxiety disorders are common in older adults; however, relatively few patients are diagnosed with these disorders in clinical practice. The occurrence of anxiety meeting the criteria for a diagnosable disorder ranges from 3.5% to 12% of older people (Flood & Buckwalter, 2009). Anxiety symptoms that may not meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 2000) criteria (subthreshold symptoms) are even more prevalent, with estimated rates from 15% to 20% in community samples, with even higher rates in medically ill populations (Ayers et al., 2006).
Older people are less likely to report psychiatric symptoms or acknowledge anxiety, and often attribute their symptoms to physical health problems. Separating a medical condition from the physical symptoms of an anxiety disorder may be difficult. The presence of cognitive impairment also makes diagnosis complicated. It is estimated that 40% to 80% of older people with Alzheimer’s disease or related dementias experience anxiety-related symptoms that may be expressed with behavior, such as agitation, irritability, pacing, crying, and repetitive verbalizations (Smith, 2005) (see Chapter 21).
Anxiety is frequently the presenting symptom of depression in older adults, and up to 60% of patients with a major depressive disorder also suffer from an anxiety disorder (Seekles et al., 2009). Anxiety disorders without comorbid depression are also common (Kolanowski & Piven, 2006). Risk factors for anxiety disorders in older people include the following: female, urban living, history of worrying or rumination, poor physical health, low socioeconomic status, high-stress life events, and depression and alcoholism.
Geriatric anxiety is associated with more visits to primary care providers and increased average length of visit. Anxiety symptoms and disorders are associated with many negative consequences including decreased physical activity and functional status, substance abuse, decreased life satisfaction, and increased mortality rates (Ayers et al., 2006; Kolanowski & Piven, 2006; Wetherell et al., 2005). Unidentified or untreated anxiety disorders in older people adversely affect well-being and quality of life.
Implications for gerontological nursing and healthy aging
Assessment
Data suggest that approximately 70% of all primary care visits are driven by psychological factors (e.g., panic, generalized anxiety, stress, somatization) (American Psychological Association, 2012). This means that nurses often encounter anxious older people and can identify anxiety-related symptoms and initiate assessments that will lead to appropriate treatment and management.
The general and pervasive nature of anxiety may make diagnosis difficult in older adults. In addition, older adults tend to deny the psychological symptoms, attribute anxiety-related symptoms to physical illness, and have coexistent medical conditions that mimic symptoms of anxiety. Some of the medical disorders that cause anxiety include cardiac arrhythmias, delirium, dementia, chronic obstructive pulmonary disease (COPD), heart failure, hyperthyroidism, hypoglycemia, postural hypotension, pulmonary edema, and pulmonary embolism.
Anxiety is also a common side effect of many drugs including anticholinergics, digitalis, theophylline, antihypertensives, beta-blockers, beta-adrenergic stimulators, corticosteroids, and over-the-counter (OTC) medications such as appetite suppressants and cough and cold preparations. Caffeine, nicotine, and withdrawal from alcohol, sedatives, and hypnotics will cause symptoms of anxiety.
Assessment of anxiety in older people focuses on physical, social, and environmental factors, as well as past life history, long-standing personality, coping, and recent events. Older people more often report somatic complaints rather than cognitive symptoms such as excessive worrying. It is important to remember that expressed fears and worries may be realistic or unrealistic, so the nurse must investigate and obtain collateral information from family or caregivers. For example, fear of leaving the home may be related to frequent falling or crime in the neighborhood. Worries about financial stability may be related to the current economic situation or financial abuse by other people.
It is important to investigate other possible causes of anxiety, such as medical conditions and depression. Diagnostic and laboratory tests may be ordered as indicated to rule out medical problems. Cognitive assessment, brain imaging, and neuropsychological evaluation are included if cognitive impairment is suspected (see Chapter 21). When comorbid conditions are present, they must be treated. A review of medications, including OTC and herbal or home remedies, is essential, with elimination of those that cause anxiety.
Interventions
Although further research is needed to provide evidence to guide treatment, existing studies suggest that anxiety disorders in older people can be treated effectively. Treatment choices depend on the symptoms, the specific anxiety diagnosis, comorbid medical conditions, and any current medication regimen. Nonpharmacological interventions are preferred and are often used in conjunction with medication (Smith, 2005).
Pharmacological
Research on the effectiveness of medication in treating anxiety in older people is limited. Age-related changes in pharmacodynamics and issues of polypharmacy make prescribing and monitoring in older people a complex undertaking. Antidepressants in the form of selective serotonin reuptake inhibitors (SSRIs) are usually the first-line treatment. Within this class of drugs, those with sedating rather than stimulating properties are preferred (e.g., citalopram, paroxetine, sertraline, venlafaxine).
Second-line treatment may include short-acting benzodiazepines (alprazolam, lorazepam) or mirtazapine. Treatment with benzodiazepines should be used for short-term therapy only (less than 6 months) and relief of immediate symptoms, but must be used carefully in older adults. Use of older drugs, such as diazepam or chlordiazepoxide, should be avoided because of their long half-lives and the increased risk of accumulation and toxicity in older people. All these medications can have problematic side effects, such as sedation, falls, cognitive impairment, and dependence. Nonbenzodiazepine anxiolytic agents (buspirone) may also be used. Buspirone has fewer side effects but requires a longer period of administration (up to 4 weeks) for effectiveness.
Nonpharmacological
Cognitive behavioral therapy (CBT), psychoeducation, skills training, and relaxation training are modalities utilized for older adults with anxiety disorders or symptoms. CBT is designed to modify thought patterns, improve skills, and alter the environmental states that contribute to anxiety. CBT may involve relaxation training and cognitive restructuring (replacing anxiety-producing thoughts with more realistic, less catastrophic ones), and education about signs and symptoms of anxiety. CBT is effective for older people but may have a lower efficacy than in younger people. Further research is needed to investigate other treatment approaches that may be used to substitute or augment this therapy for older people (Gould et al., 2012; Smith, 2005; Thorp et al., 2009). Interventions for stress management including meditation, yoga, and other therapies are also important in the treatment and management of anxiety in older people.
The therapeutic relationship between the patient and the health care provider is the foundation for any intervention. Family support, referral to community resources, support groups, and sources of educational materials, are other important interventions.
Posttraumatic stress disorder
According to the DSM-IV (American Psychiatric Association, 2000), PTSD was recognized over 20 years ago as a syndrome characterized by the development of symptoms after an extremely traumatic event that involves witnessing, or unexpectedly hearing about, an actual or threatened death or serious injury to oneself or another closely affiliated person. Individuals often reexperience the traumatic event in episodes of fear and experience symptoms such as helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance.
Individuals with PTSD may have ongoing sleep problems, somatic disturbances, anxiety, depression, and restlessness. Older adults with PTSD have high rates of several physical health conditions and poorer physical functioning (Pietrzak et al., 2012). PTSD is fairly common with a lifetime prevalence of 7% to 12% of adults, but prevalence rates among older adults have not been adequately investigated.
In the cohort of Vietnam veterans (now in the “baby boomer” cohort), PTSD prevalence is 15%. The probability of significant increases in future prevalence of PTSD is likely (Kolanowski & Piven, 2006). It occurs increasingly in women. Rape is the most likely specific trauma that will result in PTSD in women, followed by child abuse, being threatened with a weapon, being molested, being neglected as a child, and physical violence. For men, the greatest trauma is also rape, followed by abuse as a child, combat, and being molested.
PTSD has become a part of our national vocabulary and reminds us of the deep and lasting toll that war and natural disasters take. PTSD was first recognized as an outcome of overwhelmingly stressful experiences of individuals in the war in Vietnam and is now a growing concern among Gulf War and Iraq War veterans. Only recently realized is the fact that many World War II veterans have lived most of their lives under the shadow of PTSD without it being recognized.
Seniors in our care now have also experienced the Great Depression, the Holocaust, racism, and the Korean conflict—events that also may precipitate PTSD. Although they may have managed to keep symptoms under control, a person who becomes cognitively impaired may no longer be able to control thoughts, flashbacks, or images. This can be the cause of great distress that may be exhibited by aggressive or hostile behavior. There may be some association between PTSD and a greater incidence and prevalence of dementia, but further research is needed (Qureshi et al., 2010).
Older individuals who are Holocaust survivors may experience PTSD symptoms when they are placed in group settings in institutions. Bludau (2002) described this as the concept of second institutionalization. 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. Box 22-1 provides some clinical examples of PTSD.
Implications for gerontological nursing and healthy aging
Assessment
PTSD prevention and treatment are only now getting the research attention that other illnesses have received over the years. The care of the individual with PTSD involves awareness that certain events may trigger inappropriate reactions, and the pattern of these reactions should be identified when possible. Knowing the person’s history and life experiences is essential in understanding behavior and implementing appropriate interventions. An instrument to assess PTSD can be found in the Evidence-Based Practice box.
EVIDENCE-BASED PRACTICE
Mental Health Disorders in Older Adults
http://consultgerirn.org/uploads/File/trythis/try_this_19.pdf
http://consultgerirn.org/topics/depression/want_to_know_more
http://consultgerirn.org/topics/depression/need_help_stat/
http://consultgerirn.org/uploads/File/trythis/try_this_17.pdf
Detection of depression in older adults with dementia:
www.guideline.gov/summary.aspx?doc_id=11054&nbr= 005833&string=depression+and+dementia
Interventions
Effective coping with traumatic events seems to be associated with secure and supportive relationships; the ability to freely express or fully suppress the experience; favorable circumstances immediately following the trauma; productive and active lifestyles; strong faith, religion, and hope; a sense of humor; and biological integrity. Interventions such as CBT, cognitive restructuring, trauma confrontation, prolonged exposure therapy, and age-specific narrative life review approach have produced promising results for individuals with PTSD. However, further research is needed to understand the various presentations of PTSD in late life and validate and improve the effectiveness of available treatment approaches (Bottche et al., 2012; Thorp, 2009). Evidence-based psycho-spiritual interventions may also be effective in the treatment of veterans with PTSD and may be more acceptable among those who have a fear of mental illness–related stigma (Bormann et al., 2008). Medication therapy is also used, and sertraline and paroxetine have U.S. Food and Drug Administration (FDA) approval to treat PTSD.
Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is characterized by recurrent and persistent thoughts, impulses, or images (obsessions) that are repetitive and purposeful, and intentional urges of ritualistic behaviors (compulsions) that improve comfort level but are recognized as excessive and unreasonable. OCD is an anxiety disorder that significantly impairs function and consumes more than 1 hour each day (American Psychiatric Association, 2000). Among older adults, symptoms are often not sufficient to seriously disrupt function and thus may not be considered a true disorder but rather a coping strategy. If symptoms progress to a point at which they disrupt function, the elder will need clinical attention. Recommended treatments include exercise and CBT in combination with pharmacological treatment (SSRIs), if indicated.
Psychiatric symptoms in older adults
Paranoid symptoms
The 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 Alzheimer’s disease and other dementias, as well as Parkinson’s disease. New-onset paranoid symptoms are common among older adults and can present in a number of conditions in late life. Paranoid symptoms can signify an acute change in mental status as a result of a medical illness or delirium, or they can be caused by an underlying affective or primary psychotic mental disorder.
These symptoms can also manifest as a result of behavioral and psychological symptoms of dementia. Paranoia is also an early symptom of Alzheimer’s disease, appearing approximately 20 months before diagnosis. Medications, vision and hearing loss, social isolation, alcoholism, depression, the presence of negative life events, financial strain, and PTSD can also be precipitating factors in paranoid symptoms (Chaudhary & Rabheru, 2008).
Delusions
Delusions are beliefs that guide one’s interpretation of events and help make sense out of disorder, even though they are inconsistent with reality. The delusions may be comforting or threatening, but they always form a structure for understanding situations that otherwise might seem unmanageable. A delusional disorder is one in which conceivable ideas, without foundation in fact, persist for more than 1 month.
Common delusions of older adults are of being poisoned, of children taking their assets, of being held prisoner, or of being deceived by a spouse or lover. In older adults, delusions often incorporate significant persons rather than the global grandiose or persecutory delusions of younger persons. Fear and a lack of trust originating from a basis in reality may become magnified, especially when one is isolated from others and does not receive reality feedback. Many delusions related to family members and their actions or intentions occur among institutionalized older people. Some may aid in coping, whereas others may be troubling to the person. One study found that 21% of 125 new nursing home residents had delusions (Grossberg, 2000). It is always important to determine if what “appears” to be delusional ideation is, in fact, based in reality.
Hallucinations
Hallucinations are best described as sensory perceptions of a nonexistent object and may be spurred by the internal stimulation of any of the five senses. Although not attributable to environmental stimuli, hallucinations may occur as a combined result of environmental factors. Hallucinations arising from psychotic disorders (e.g., schizophrenia) are less common among older adults, and those that are generated are thought to begin in situations in which one is feeling alone, abandoned, isolated, or alienated.
The character and stages of hallucinatory experiences in late life have not been adequately defined. Many hallucinations are in response to physical disorders, such as dementia, Parkinson’s disease, sensory disorders, and medications. Hallucinations of older adults most often seem mixed with disorientation, illusions, intense grief, and immersion in retrospection, the origins being difficult to separate. Older people with hearing and vision deficits may also hear voices or see people and objects that are not actually present (illusions). Some have explained this as the brain’s attempt to create stimulation in the absence of adequate sensory input. If illusions or hallucinations are not disturbing to the person, they do not necessitate treatment.
Implications for gerontological nursing and healthy aging
Assessment
The assessment dilemma is often one of determining if paranoia, delusions, and hallucinations are the result of medical illnesses, medications, dementia, psychoses, deprivation, or overload because the treatment will vary accordingly. Treatment must be based on a comprehensive assessment and a determination of the nature of the psychotic behavior (primary or secondary psychosis) and the time of onset of first symptoms (early or late). Treating the underlying cause of a secondary psychosis caused by medical illnesses, dementia, substance abuse, or delirium is a priority (Mentes & Bail, 2005).
Assessment of vision and hearing is also important since these impairments may predispose the older person to paranoia or suspiciousness. Psychotic symptoms and/or paranoid ideation also present with depression, so depression screening should also be conducted. Assessment of suicide potential is also indicated because individuals experiencing paranoid symptoms are at significant risk for harm to self.
It is never safe to conclude that someone is delusional or paranoid or experiencing hallucinations unless you have thoroughly investigated his or her claims, evaluated physical and cognitive status, and assessed the environment for contributing factors to the behaviors.
Interventions
Frightening hallucinations or delusions, such as feeling that one is being poisoned, usually 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, and attending to the fears more than to the content of the delusion or hallucination. Direct confrontation and arguing is never a useful approach and is likely to increase anxiety and agitation and the sense of vulnerability; it also may disrupt the relationship. A more useful approach is to establish a trusting relationship that is nondemanding and not too intense.
It is important to identify the client’s strengths and build on them. Demonstrating respect and a willingness to listen to complaints and fears is important and the basis for a caring nurse-patient relationship. It is important that the nurse be trustworthy, give clear information, and present clear choices. Do not pretend to agree with paranoid beliefs or delusions, but rather ask what is troubling to the person and provide reassurance of safety. It is important to try to understand the person’s level of distress as well as how he or she is experiencing what is troubling. For institutionalized older people, other suggestions are to avoid television, which can be confusing, especially if the person awakens and finds it on or has a hearing or vision impairment. In addition, reduce clutter in the person’s room and eliminate shadows that can appear threatening. Provide glasses and hearing aids to maximize sensory input and decrease misinterpretations.
If symptoms are interfering with function and interpersonal and environmental strategies are not effective, antipsychotic drugs may be used. The newer atypical antipsychotics (risperidone, olanzapine) are preferred but must be used judiciously, with careful attention to side effects and monitoring of response. In the case of depression with psychotic features, combination therapy with an antidepressant and an atypical antipsychotic agent may be useful.
In cognitively impaired individuals with paranoid ideation, there is some evidence suggesting that treatment with cognitive enhancer medications (cholinesterase inhibitors and memantine) may be of benefit. If symptoms interfere with function and safety, and nonpharmacological interventions are not effective, antipsychotic medications may be used. However, none of the antipsychotic medications are approved for use in treatment of behavioral responses in dementia. The benefits are uncertain, and adverse effects offset any advantages (Schneider et al., 2006).
Psychoeducation, individual or group therapy, environmental and behavioral modification strategies, and supportive environments are also important treatment considerations. The presence of these symptoms contributes to caregiver burden and stress, and they are often precipitating factors to institutionalization, so caregiver support and utilization of community resources is important. See Chapter 21 for further discussion of behavior and psychological symptoms in dementia and nonpharmacological interventions.
Schizophrenia
Schizophrenia is a severe mental disorder characterized by two or more of the following symptoms: delusions, hallucinations, disorganized thinking, disorganized or catatonic behavior (called positive symptoms) and affective flattening, poverty of speech, or apathy (called negative symptoms) that cause significant social or occupational dysfunction, and are not accompanied by prominent mood symptoms or substance abuse or can be attributed to medical causes (American Psychiatric Association, 2000). The diagnostic criteria for schizophrenia are the same across the life span.
People with schizophrenia are the largest group of older people with severe mental health problems, and the numbers are expected to grow over the next decade with the increased longevity of the population. As Evans (2008) notes: “Persons living with mental illness also grow old and the changes associated with aging may further compromise a lifetime of challenged coping, thus exacerbating symptomatology and well-being” (p. 2). Although the onset of schizophrenia usually occurs between adolescence and the mid-30s, it can extend into and first appear in late life. However, 85% of older people with schizophrenia were diagnosed before age 45 (Berry & Barrowclough, 2009).
Prevalence of schizophrenia in older people is estimated to be approximately 0.6%—about half of the prevalence in younger adults. Distinction is made between early-onset schizophrenia (EOS), occurring before age 40; midlife onset (MOS), between ages 40 and 60; and late onset schizophrenia (LOS), after age 60. There is some suggestion that there may be neurobiologic differences between EOS and LOS, and further investigation is needed.
Patients with LOS are more likely to be women, and paranoia is the dominant feature of the illness. They tend to have a greater prevalence of visual hallucinations, less prevalence of a formal thought disorder, fewer negative symptoms, and less family history of schizophrenia. Women with LOS are also at greater risk for tardive dyskinesia, have less impairment in the areas of learning and abstraction, and require lower doses of neuroleptic medications for symptom management (Smith, 2005). Individuals with EOS who have grown older may experience fewer hallucinations, delusions, and bizarre behavior as well as inappropriate affect. Positive symptoms may wane, whereas negative symptoms tend to persist into late life (Mentes & Bail, 2005).
Implications for gerontological nursing and healthy aging
Interventions
Treatment for schizophrenia includes both medications and environmental interventions. Conventional neuroleptic medications (e.g., haloperidol) have been effective in managing the positive symptoms but are problematic in older people and carry a high risk of disabling and persistent side effects, such as tardive dyskinesia (TD). The Abnormal Involuntary Movement Scale (AIMS) is useful for evaluating early symptoms of TD. The newer atypical antipsychotic medications (e.g., risperidone, olanzapine, quetiapine), given in low doses, are associated with a lower risk of extrapyramidal symptoms (EPS) and TD. Federal guidelines for the use of antipsychotic medications in nursing homes provide the indications for use of these medications in schizophrenia. Other important interventions include a combination of support, education, physical activity, and CBT.
Families of older people with schizophrenia experience the burden of caring for a family member with a chronic disability as well as dealing with their own personal aging. Community-based support services are needed that include assistance with housing, medical care, recreation services, and services that help the family plan for the future of their relative. There are relatively few services in the community for older persons with schizophrenia. The National Alliance for the Mentally Ill (NAMI) (www.nami.org) is an important resource for clients and their families (Mentes & Bail, 2005).
Individuals with severe persistent mental illnesses such as schizophrenia form a disenfranchised group whose access to medical care has been limited, leading to greater functional declines, morbidity, and mortality (Davis, 2004). Schizophrenia is a costly disease both in terms of personal suffering and medical care costs. An estimated 41% of older people with schizophrenia now reside in nursing homes (Leutwyler & Wallhagen, 2010). Interventions to improve independent functioning irrespective of age and in conjunction with community services would decrease the expenses associated with institutionalization (Madhusoodanan & Brenner, 2007, p. 30).
Bipolar disorder
Bipolar disorder is not common in late life, but recurrence of remitted disease does occur. It is anticipated that with the growing number of older people, more cases will be seen. Ten percent of inpatient psychiatric admissions among older adults are for bipolar disorder. The disease occurs more often among individuals 60 to 64 years of age, with a declining incidence in older cohorts (Sherrod et al., 2010). Bipolar disorders, characterized by periods of mania and depression, often level out in late life, and individuals tend to have longer periods of depression. Mania is a more frequent cause of hospitalization than depression, but depression may account for more disability. Similar to other psychiatric disorders in older adults, comorbidities often mask the presence of the disorder and it is frequently misdiagnosed, underdiagnosed, and undertreated (Kennedy, 2008).
Implications for gerontological nursing and healthy aging
Assessment
Assessment includes a thorough physical examination and laboratory and radiological testing to rule out physical causes of the symptoms and identify comorbidities. A medication review should be conducted since symptoms can be a side effect of medications such as antidepressants, benzodiazepines, amphetamines, prednisone, and captopril. Obtaining an accurate history from the individual, as well as the family, is important and should include assessment of symptoms associated with depression, mania, hypomania, and a family history of bipolar disorder.
The genetic basis of the disease is being investigated, and two genes that influence the activity of nerve cells in the brain may play a key role in an individual’s risk for bipolar disorder. Sherrod and colleagues (2010) provide two algorithms for the appropriate diagnosis and management of bipolar disorder, and the National Institute of Mental Health (NIMH) provides comprehensive information on the diagnosis and treatment of bipolar disorder (www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml).
Interventions
Lithium, the most commonly used substance for individuals with bipolar disorders, has neurological effects that make it difficult for older people to tolerate; it also has a long half-life (more than 36 hours). Careful monitoring of blood levels and patient response is important. Recommended treatment consists of a combination of one or more mood stabilizers (e.g., lithium, valproic acid, carbamazepine, lamotrigine). If the patient does not respond to these medications, atypical antipsychotic drugs are possible alternative treatments, but with the same safety warnings discussed earlier and are not to be used if dementia is suspected. Olanzapine, aripiprazole, and seroquel are all approved for the treatment of bipolar disorder and may relieve symptoms of severe mania and psychosis (see www.nimh.nih.gov/publications/bipolar-disorder/complete-index.shtml). Electroconvulsive therapy (ECT) may also be used when medication and/or psychotherapy are not effective.
Patient and family education and support are essential, and the family must understand that the individual is not able to control mania and irritating behaviors because of a chemical imbalance in the brain. Treatment with medication and intensive psychotherapy, CBT interpersonal and rhythm therapy (improving relationships with others and managing regular daily routines), or family-focused therapy has been reported to be effective in decreasing relapses, preventing hospitalization, and improving adherence to treatment plans (National Institute of Mental Health [NIMH], 2009).
Depression
Depression is not a normal part of aging, and studies show that most older people are satisfied with their lives, despite physical problems. To understand depression, the nurse must understand the influence of late-life stressors and changes, culture, and the beliefs older people, society, and health professionals may have about depression and its treatment.
Prevalence and consequences
Depression is the most common mental health problem of late life and among the most treatable, but it can be life-threatening if unrecognized and untreated. The prevalence of major depression in older adults (1% to 5%) is somewhat lower than that in the general population, but minor depression and depressive symptoms are experienced by a large number of older people (Evans, 2008). One in 10 older adults visiting a physician suffers from depression (see http://impact-uw.org/).
Estimates of prevalence vary widely depending on the qualitative variables being considered and the definition being used. The prevalence of major depression in home care recipients ranges from 12% to 26%, but depressive symptoms are present in as many as 57% of this population. Among homebound older adults, two thirds with clinically significant depression had not received treatment (Sirey et al., 2008). For older adults in nursing homes, the prevalence of depressive symptoms may be as high as 54%, and a recent study reported that 23% were not treated and only 2.5% received some form of behavioral therapy. Depression is a major reason why older people are admitted to nursing homes (Kurlowicz & Harvath, 2008a; Morley, 2010).
Depression and illness are likely to co-occur. Becoming sick doubles the probability of becoming depressed, and becoming depressed doubles the probability of becoming sick (Thielke et al., 2010). More than 15% of older adults with chronic physical conditions are depressed, and depression has been called “the unwanted cotraveler” accompanying many medical illnesses (Byrd, 2005, p. 132). Many medications that older people may take can also cause depression.
Depression is a major source of morbidity in older adults (Heller et al., 2010). Depression and depressive symptomatology are associated with negative consequences such as increased disability, delayed recovery from illness and surgery, excess use of health services, cognitive impairment, malnutrition, decreased quality of life, and increased suicide and non–suicide-related death (Evans, 2008; Kurlowicz & Harvath, 2008b). Depression remains underdiagnosed and undertreated, and major depressive disorder (MDD) is undiagnosed in approximately half of older persons with this disorder (Das et al., 2007).
The stigma associated with depression may be more prevalent in older people, and they may not acknowledge depressive symptoms or seek treatment. Many elders, particularly those who have survived the Great Depression, both world wars, the Holocaust, and other tragedies, may see depression as shameful, evidence of flawed character, self-centered, a spiritual weakness, and sin or retribution.
Health professionals often expect older people to be depressed and may not take appropriate action to assess for and treat depression. The differing presentation of depression in older people, as well as the increased prevalence of medical problems that may cause depressive symptoms, also contributes to inadequate recognition and treatment. Even if depression is identified, only about one half of Americans diagnosed with a major depression receive treatment for it, and even fewer, about one fifth, receive treatment consistent with current guidelines (Gonzalez et al., 2010).
Ethnic and cultural considerations
Depression diagnosis and treatment is an even greater concern for ethnically and culturally diverse elders. African Americans and African Caribbeans who experience a major depressive episode are more likely to be untreated, and they experience more disabling effects than non-Hispanic whites. Mexican-American and African-American individuals with depression have the lowest rates of depression care and treatment in accordance with accepted guidelines (Gonzalez et al., 2010). Nursing home patients who are female, black, or cognitively impaired are less likely to receive treatment for depression (Byrd, 2005; Kurlowicz & Harvath, 2008a).
Failure to treat depression increases morbidity and mortality. There is no evidence that current evidence-based treatments for geriatric depression, such as psychotherapy, psychosocial interventions, and medications, are any less effective as people age (Kurlowicz & Harvath, 2008a; Thielke et al., 2010). It is highly likely that nurses will encounter a large number of older people with depressive symptoms in all settings. Recognizing depression and enhancing access to appropriate mental health care are important nursing roles to improve outcomes for older people.
Etiology
The causes of depression in older adults are complex and must be examined in a biopsychosocial 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. Biologic causes, such as neurotransmitter imbalances or dysregulation of endocrine function, have also been proposed as factors influencing the development of depression in late life (Kurlowicz & Harvath, 2008a).
Some of the medical disorders that cause depression are cancers; cardiovascular disorders; endocrine disorders, such as thyroid problems and diabetes; neurological disorders, such as Alzheimer’s disease, stroke, and Parkinson’s disease; metabolic and nutritional disorders, such as vitamin B12 deficiency and malnutrition; viral infections, such as herpes zoster and hepatitis; and advanced macular degeneration. Among patients who have suffered a cerebral vascular accident, the incidence of major depressive disorder is approximately 25%, with rates being close to 40% in patients with Parkinson’s disease (Das et al., 2007). Vascular depression is a term being used to describe a late-life depression associated with vascular changes in the brain and characterized by executive dysfunction (Thakur & Blazer, 2008).
Serious symptoms of depression occur in up to 50% of older adults with Alzheimer’s disease and are associated with increased mortality, reduced quality of life, increase in caregiver burden and distress, and higher rates of institutionalization (Chang & Roberts, 2011; Gellis et al., 2009). Depression in individuals with Alzheimer’s disease may be due to an awareness of progressive decline, but research suggests that there may be a biological connection between depression and Alzheimer’s disease as well (Friedman et al., 2009; Kurlowicz & Harvath, 2008a; Morley, 2010).
Medications may also result in depressive symptoms including hypertensives, angiotensin-converting enzyme (ACE) inhibitors, methyldopa, reserpine, guanethidine, antidysrhythmics, anticholesteremics, antibiotics, analgesics, corticosteroids, digoxin, and L-dopa (Kurlowicz & Harvath, 2008b).
Other important factors influencing the development of depression are alcohol abuse, loss of a spouse or partner, loss of social supports, lower income level, caregiver stress (particularly caring for a person with dementia), and gender. Some psychological traits, such as neuroticism, pessimistic thinking, and being less open to new experiences, have been found to be associated with higher rates of depression and suicide (Das et al., 2007). Some common risk factors for depression are presented in Box 22-2.
BOX 22-2
Risk Factors for Depression in Older Adults
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