Geropsychiatric Nursing



Geropsychiatric Nursing


Georgia L. Stevens




Learning Objectives



1. Examine the dimensions of mental illness in the elderly population and the role of the geropsychiatric nurse.


2. Compare the major biopsychosocial theories of aging.


3. Discuss the elements of a comprehensive geropsychiatric nursing assessment.


4. Formulate nursing diagnoses for geropsychiatric patients.


5. Analyze evidence-based nursing interventions for geropsychiatric patients.


6. Evaluate nursing care of geropsychiatric patients.



People age 85 years or older make up the fastest growing age group in the United States. By the year 2030, older adults will make up 20% of the population. By the year 2050, the oldest old (85 years or older) group will increase to between 24% and 30% of the total population. With projections of 10 to 14 million people requiring long-term care, this segment of the population will drive up the demand for services and programs that address chronic physical and mental illness and disability. The demographics of aging and mental health make geropsychiatric nursing the specialty of the future.


The future elderly population will be especially diverse. Socioeconomic factors that will affect the elderly’s status are advances in health care and changes in the labor force, family structure, and caregiver characteristics. Many of the elderly will be better educated, healthier, and wealthier than those at the end of the twentieth century, resulting in a rethinking of our concepts of retirement, aging, and health care.


Minority groups are projected to have the highest growth rates as they become emerging majorities (Touhy and Jett, 2010). Historically, minority groups have had lower socioeconomic status and less access to health care. For many elderly people, disparity among health, income, and education levels will increase, presenting public health and policy challenges (Bell and McBride, 2011).


The elderly population has doubled approximately three times since 1900. Although this group has increased by more than 100% since 1960, the general population has increased by only 50%. This increase in the elderly-to-dependency ratio (the ratio of the elderly to the working-age population) will negatively impact the financial support of social programs such as Medicare, Social Security, and other federal and state health care and disability programs unless functional levels of the oldest old continue to improve or their labor force participation continues to increase.



Mental Illness in the Elderly Population


Mental illness is not an inevitable part of aging, although many older adults experience mental health and substance use conditions, some with diminished functional capacity. As mortality rates for younger mentally ill patients decrease, many mentally ill individuals will live into old age. It is anticipated that aging baby boomers (those born between 1946 and 1964), who number 75 million in the United States, will be at greater risk for substance abuse, anxiety disorders, and depression than the current group of elders. These projections, coupled with a reduction in stigma, will increase the need and demand for specialty mental health services.


The current group of older adults with mental health problems has relied on their primary care providers for management of all their health needs. The occurrence of mental illness is underestimated in nonpsychiatric settings because symptoms may be incorrectly attributed to physical disorders, normal aging, cognitive impairment, or the lack of age-appropriate diagnostic criteria. Illnesses such as depression and anxiety are often misdiagnosed or undertreated (Aschbrenner et al, 2011). The comorbidity of somatic and psychiatric illnesses makes accurate diagnosis more difficult. Public resources for health care for older adults are increasingly jeopardized, with proposed Medicare and Medicaid reductions or reorganizations. The economic and personal costs of mental disorders of older adults are considerable.


On the positive side, there have been impressive changes in academic and research interests in aging and the elderly. New scientific findings about normal aging and the cause and treatment of mental disorders have been combined with concepts of health promotion and preventive medicine to address what is possible with aging. The importance of understanding potential in relation to aging is necessary to enable older people to access latent skills and talents in later life, strengthen positive lifestyle habits, and challenge current younger age groups to think differently about what is possible for them in their later years: aging well (Jeste and Depp, 2010).


Helping older adults maximize their potential can be a challenging and rewarding experience for the nurse. The opportunity to share the wisdom and resilience of an older adult can make this specialty area especially rewarding (Cangelosi, 2007; Reichstadt et al, 2010).


Although stereotypes and myths often depict elderly people as a homogeneous group, older adults have a wide range of biological, interpersonal, developmental, and situational experiences. The complexity and interaction of the needs and problems of old age are often understated and misunderstood. Mental health in late life depends on a number of factors, including physiological and psychological status, personality, social support system, economic resources, and usual lifestyle.



Role of the Geropsychiatric Nurse


Demographic shifts and the shortage of nurses have increased the demand for nurses who work with older adults with mental disorders (Institute of Medicine, 2008; Loge and Sorrell, 2010). Major initiatives by the Hartford Institute for Geriatric Nursing (HIGN), the American Academy of Nursing Geropsychiatric Nursing Collaborative (GPNC), and the American Association of Colleges of Nursing Geriatric Nursing Education Consortium (GNEC) program provide significant support and resources for manpower development and quality clinical outcomes by easy access to timely, significant, and evidence-based information (Box 37-1).



BOX 37-1   GEROPSYCHIATRIC NURSING ONLINE RESOURCES∗




∗All websites accessed November 2011.


Geropsychiatric nursing practice offers flexibility in clinical practice settings. Mental health services are provided to this population in a variety of settings, including primary care, general and psychiatric hospitals, nursing homes, assisted living residential centers, outpatient mental health clinics, adult day-care programs, senior centers, and the person’s own home.


The nurse who works with older adults with mental illness is challenged to integrate psychiatric nursing skills with knowledge of physiological disorders, the normal aging process, and sociocultural influences on elderly people and their families. Many nurses who work with these patients welcome the opportunity to integrate nurse practitioner and psychiatric nursing skills.


As a primary care provider, the geropsychiatric nurse should be proficient at assessing patients’ cognitive, affective, functional, physical, and behavioral status, as well as their family dynamics. Geropsychiatric nursing is a collaborative partnership with the older adult, family or other caregivers, and the interdisciplinary team. Providing nursing care to these patients can be complex because they are often involved with a number of agencies requiring coordination of services.


Geropsychiatric nurses should be knowledgeable about somatic and interpersonal treatments, including the safe use of psychotropic medication with elderly people. They often work closely with physician and nurse prescribers to monitor complex medication regimens and help the patient or caregiver with medication management. They may lead a variety of groups, such as healthy aging, remotivation, bereavement, and socialization groups, whereas nurses with advanced degrees may also provide psychotherapy and prescribe medications.


As a consultant, the geropsychiatric nurse helps other providers address the behavioral, social, and cognitive aspects of the patient’s care. For instance, a nurse may help nursing assistants understand how to respond to a person who wanders or one who is aggressive. Advanced practice geropsychiatric nurses may be employed by agencies to help the entire staff develop therapeutic evidence-based programs for seniors with psychiatric or behavioral issues resulting in improved clinical outcomes.


The role of patient advocate is a critical one for the nurse caring for elders with mental illnesses, particularly those with concurrent physical illness. Because of stigma, cognitive changes, or symptoms of acute or chronic health problems, elders may not be able to effectively voice their wishes or concerns. Sensitivity is required when addressing the families of seriously mentally ill individuals because they might have been dealing with “caregiving challenges” for many years.


Reviewing legal options such as an advance directive or living will helps in the promotion of the elder’s wishes. When conflict exists regarding the elder’s care, particularly in long-term care settings, an ombudsman or guardian may be contacted to help resolve these issues. Information about ombudsman or other advocacy programs for the elderly may be obtained by contacting any local office on aging.



Theories of Aging


Theories of aging provide a perspective on the possible causes and consequences of the aging process. Although the theories do not directly guide care, they address underlying values that influence how one understands, evaluates, and cares for geriatric patients. New evidence of the impact of healthy living on aging well is challenging the basis of some of these theories.



Biological Theories


Biological theories of aging address genetic, systemic, and cellular approaches:




Critical Reasoning


Give two examples that raise questions about the biological programming theory of aging. How do you feel about the idea of a biological clock determining life span?



Specific system theories: Neuroendocrine and immune systems become less effective in surveillance, self-regulation, and response, causing aging.


Cross-linkage theory: Collagen forms bonds between molecular structures, causing increasing rigidity over time.


Error theory: Errors manifested during protein synthesis create error cells that then multiply.


Free radical theory: Free radicals damage cell membranes, causing physical damage and decline.


Gene theories: Harmful genes activate in late life; cell divisions are finite; or failure to produce growth substances stops cell growth and division.


Stress adaptation theory: The positive and negative effects of stress on biopsychosocial development are emphasized. Stress may drain a person’s reserve capacity physiologically, socially, and economically, increasing vulnerability to illness or injury, accelerating the aging process.


Wear-and-tear theory: Cells wear out from internal and external causes. Structural and functional changes may be speeded by abuse and slowed by care. This theory is the basis of many myths and stereotypes (“What can you expect from someone his age?”).



Critical Reasoning


Discuss how the wear-and-tear theory of aging compares with the current emphasis on nutrition and physical fitness in U.S. culture.




Sociocultural Theories


Sociocultural theories of aging address the interplay of the individual and the environment:




Critical Reasoning


What type of program would you design for older adults who must stop working or participating in community activities?





Assessment


Nursing assessment of the geropsychiatric patient is complex. The interplay of biological, psychological, and sociocultural factors related to aging may make it difficult to differentiate nursing problems. It can be hard to sort out the behaviors related to the 4 D’s of geropsychiatric assessment: depression, dementia, delirium, and delusions (see Chapter 22). The co-existence of simple medical problems, such as a urinary tract infection or dehydration, can exacerbate behavioral symptoms.


For example, delusions can be part of psychotic depression in elders, and those with dementia may seem delusional because of the trouble they have in interpreting the environment. Delirium is common with significant morbidity and mortality among older adults (Botts, 2010). It has an acute onset and may occur as a reaction to physical illness, medications, or sensory deprivation. Behaviors associated with delirium may fluctuate and include marked psychomotor changes, changing level of consciousness, disorientation, and short attention span. Delirium may be mistaken for dementia, thereby depriving the patient of treatment to remedy the problem. Nurses are in an ideal position to lead efforts in delirium evaluation, prevention, and treatment.


Depressed elders may appear confused and cognitively impaired because of the lethargy and psychomotor retardation related to depression. Patients with dementia also may present with anxiety, agitation, and depression, especially if they are aware of their declining mental functioning. The onset of depression in later life is associated with greater chronicity, relapse, cognitive dysfunction, and an increased rate of dementia (Schultz, 2011).


Certain behaviors may help differentiate between depression and dementia. Depressed patients are oriented and maintain socially appropriate behaviors. They are unlikely to undress in public or be incontinent. Depressed patients may be annoyed and reject the questioner with silence or short, unresponsive answers. In contrast, patients with dementia may behave inappropriately and will try to answer questions but have trouble with logic and relevance. Irritability is characteristic of depression, whereas mood variability in patients with late-onset depression may be an early symptom of dementia (Verkaik et al, 2009).


Careful nursing assessment is essential in identifying the primary disorder. Nursing diagnoses are based on observation of patient behaviors and are related to current needs. A comprehensive nursing assessment sets the stage for the rest of the nursing process (Table 37-1).




The Interview


Establishing a supportive and trusting relationship is essential to fostering a positive interview with the geriatric patient. The elderly person may feel uneasy, vulnerable, and confused in a new place or with strangers. Patience and attentive listening promote a sense of security. Comfortable surroundings help the patient relax and focus on the conversation.



Therapeutic Communication Skills


Addressing the patient by last name shows respect: “Good morning, Mr. Smith.” Open the interview by introducing yourself and briefly orienting the patient to the purpose and length of the interview. Occasionally, reinforcing the amount of time left may help direct a wandering discussion and give the patient the security of knowing that the nurse is in control of the situation.


Older adults may respond to questions slowly because verbal response slows with age. It is important to give the person enough time to answer and not assume that a slow response is due to a lack of knowledge, comprehension, or memory.


Language is important because older people often are unfamiliar with slang, colloquialisms, jargon, abbreviations, or medical terminology. Choice of words should be based on knowledge of the person’s sociocultural background and level of formal education.


Questions should be short and to the point, particularly if the patient has difficulty with abstract thinking and conceptualization. Techniques such as clarification, restating, and focusing, described in Chapter 2, are important in validating information. The nurse should rephrase a question if the patient does not answer appropriately or hesitates when answering.


Concentrated verbal interaction may be uncomfortable for the older person. Demonstrate interest and support by giving nonverbal cues and responses, such as direct eye contact, nodding, sitting close to the patient, and using touch appropriately. Touching the shoulder, arm, or hand of the patient in a firm, purposeful manner may convey support and interest. Avoid stroking or patting the patient. Cultural background and altered tactile perception may result in misinterpretation.


The nurse’s ability to collect useful data depends greatly on how comfortable the nurse feels during the interview. Negative feelings about older adults or ignorance about aging will surface in an interview. Older people are sensitive to others’ disregard, lack of interest, and impatience.


Older adults have much to tell and active listening is validating. Reminiscence and life review may be an excellent source of data about patients’ current health problems and support resources, as well as their history. Even though keeping the patient focused on the topic at hand may be difficult, these formats allow the nurse to assess subtle changes in long-term memory, decision-making ability, judgment, affect, and orientation to time, place, and person.


Although older adults may be aware of changes in their physical or psychological functioning, they may hesitate to have their fears confirmed. They may minimize or ignore symptoms, assuming that they are related to age and not to current medical or psychiatric problems. These beliefs may be reinforced by myths about aging and the false assumption of many health professionals that the problems of older people are irreversible or untreatable.


Contrary to popular myths, most older people do not dwell unrealistically on their health. However, some older people are preoccupied with the physical decline that occurs with age. The nurse should observe carefully for clues that help distinguish whether the patient’s preoccupation reflects lifelong personality factors or current distress.


Older adults may not understand the purpose of the nurse’s questions. Questions about habits, previous life experience, or social supports may not seem to be related to current concerns. Careful and repeated explanations strengthen the therapeutic alliance. The nurse should never assume that the patient understands the purpose for the assessment interview. It is better to overstate than to increase the patient’s anxiety and stress by omitting information. The nurse should take cues from the patient’s responses by listening carefully and observing constantly.



Critical Reasoning


What special challenges are you likely to face in obtaining informed consent for treatment from a geriatric patient? How can you deal with them?



The Interview Setting


The new and unfamiliar surroundings of the health care setting may distract the patient and increase fear of the unknown. If possible, the nurse should assess the patient in a familiar environment to reduce the patient’s anxiety. The physical environment should promote comfort. Chairs should be comfortable. Because many older people are unable to sit for long periods because of arthritis or other joint disabilities, changing positions can be encouraged.


Most older people experience some form of sensory deficit, particularly diminished high-frequency hearing or changes in vision as a result of cataracts or glaucoma. The setting should be quiet and without distracting noises. The nurse should speak slowly and in a low-pitched voice. Because fatigue may contribute to diminished mental functioning and patients may tire as the day progresses, morning may be the best time for the interview.


The reliability of the data obtained from the assessment interview should be carefully evaluated. If there are questions about some of the patient’s responses, the nurse should consult family members or other people who know the patient well. The nurse also should consider the impact of the patient’s physical condition at the time of the interview and other factors, such as medications, nutrition, or anxiety level.



Mental Status Examination


A mental status examination should be part of the geropsychiatric assessment because of the following:



An in-depth discussion of the assessment of mental status is presented in Chapter 6.



Depression


Affective status is an essential part of geropsychiatric assessment. The need to include a depression assessment is based on the following:



Estimates of the prevalence of depression among the elderly in medical outpatient clinics are 7% to 36% (Brandon et al, 2011). The incidence of depression among people of all ages who have disabilities is higher. The number of physical disabilities tends to increase with age, which may account for some of the prevalence in the elderly. Estimates of the prevalence for those in long-term care facilities range from 9% to 49% (Adams-Fryatt, 2010). Depression is discussed in Chapter 18.


Depression in the elderly population is frequently unrecognized and untreated. This may be because its presentation differs from that in younger populations (e.g., physical complaints), it may be assumed to be part of the normal aging process, or the diagnosis may be complicated by co-morbidity issues (Naegle, 2011). Depression may begin with decreased interest in usual activities and lack of energy. There may be an increased sense of helplessness and dependence on others. Conversation may focus almost entirely on the past.


There may be multiple somatic complaints with no diagnosable organic cause. The person may have pain, especially in the head, neck, back, or abdomen, with no history or evidence of a physical cause. Other symptoms in the elderly include sleep changes, weight loss, cognitive complaints, irritability/hostility, gastrointestinal distress, and refusal to eat or drink, with potentially life-threatening consequences.


Physical illness can cause secondary depression. Some illnesses that tend to be associated with depression include thyroid disorders, cancer (especially of the lung, pancreas, and brain), Parkinson disease, stroke, and dementia. Vascular depression has been identified from the association between depression and vascular lesions in the brain.


Many medications routinely prescribed for older people can also increase depression. Examples include antianxiety drugs and sedative-hypnotics, antipsychotics, cardiotonics (e.g., digoxin), and steroids. A medication history is an essential part of assessment, especially for the elderly, most of whom may take multiple medications.




Psychosis


Although the prevalence of schizophrenia is estimated to be only 0.6% among older adults, with about one fourth of those having late-onset (after age 40 years) disorders, the prevalence of psychotic symptoms increases with age. The nurse may find psychotic symptoms during the assessment of older adults related to delusional disorder, delirium, dementia, depression with psychosis, substance abuse, or very-late-onset psychosis after age 60 years. Clinical risk factors for developing psychosis in later life include cognitive impairment, sensory impairments (vision and hearing), social isolation, female gender, confinement to bed with a conflicted caregiver relationship, somatic co-morbidity, multiple medications, or underlying medical disorders.


Patients with a psychiatric diagnosis of psychosis may respond to supportive therapy and low doses of atypical antipsychotic drugs. Therapeutic doses for older adults with schizophrenia are significantly lower than those for younger adults.



Behavioral Responses


A thorough behavioral assessment is an essential part of planning nursing care for an elderly person. Behavioral changes may be the first sign of many physical and mental disorders. It is important to identify who is bothered by the behavior—the patient, the family, peers, or unrelated caregivers. Difficult behaviors are variously referred to as behavior problems, disruptive behaviors, disturbing behaviors, and challenging behaviors. The last is the better term to use because it reinforces the nurse’s role in understanding what the behavior is communicating.


If possible, the initial assessment should be completed in a familiar environment to capitalize on environmental factors that reduce the elder’s anxiety. It can also give the nurse a chance to observe possible triggers of disruptive behavior. Family members or other caregivers can be asked about their usual responses to the patient’s behavior, especially what is helpful and unhelpful. This may provide further clues about the source of the behavior.


It is helpful to know why the behavior is bothersome. Elders and their families may be frightened by changes in behavior because they associate them with deterioration and the possible onset of dementia. Based on the assessment, the cause of the problem may be treated and the person returned to prior levels of function. For instance, a woman who is agitated because of an undiagnosed urinary tract infection returns to her usual calm self after the infection is treated.


In some cases, it may not be possible to remove the cause of the behavior, but nursing intervention can help the patient and family adapt to it. For example, a man is irritable because he is becoming forgetful. Early Alzheimer disease is diagnosed. The patient becomes less irritable after the nurse teaches him and his family ways to maximize his memory. Behavioral changes related to declining cognitive functioning are often difficult to manage and require creative treatment.


Behavioral assessment involves defining the behavior, its frequency, duration, and precipitating factors or triggers, including the environment. When a behavioral change occurs, it is important to analyze the underlying cause and meaning. For instance, the person may be experiencing a threat to self-esteem or a change in sensory input.


A complete physical examination is needed after any abrupt behavioral change to rule out delirium (Botts, 2010). Caregiver response to behavior also must be assessed because it may reinforce or increase challenging behaviors. Common challenging behaviors (behavioral excesses) in the elderly are listed in Box 37-2.



BOX 37-2   CHALLENGING BEHAVIORS OBSERVED IN GEROPSYCHIATRIC PATIENTS





Critical Reasoning


Mr. Jones, an elderly patient, strikes out at the staff every morning when he is approached at bath time. Describe the steps you can take to assess this behavior. What questions can you ask his family? What advice can you give to the staff members who work with him?



Functional Abilities


Emotional health and overall functional ability are interrelated and cognitive impairment contributes to functional decline. This discussion emphasizes the aspects of the functional assessment that have the greatest impact on mental and emotional status.



Mobility


Mobility and independence are important to the elder’s perception of personal health. Three aspects of mobility should be assessed:



In assessing ambulation, the nurse should address motor losses, adaptations made, use of assistive devices, balance, eyesight, and the amount and type of help needed. Factors that influence ambulation include restriction of joints caused by degenerative diseases, orthostatic hypotension, and the type and fit of footwear. Motor ability of the arms can be tested by observing the patient comb hair, shave, dress, and eat.


Many medications taken by older adults alter perception, making ambulation and mobility difficult and contributing to falls. These effects are particularly caused by sedative-hypnotic, antianxiety, cardiovascular, and hypertensive drugs. Patients should be cautioned about side effects of medications and should be encouraged to take time when ambulating and moving from one position to another.


The incidence of falls and negative outcomes increases with age; 30% of people older than 65 years fall every year, with women falling at twice the rate of men. Falls result in physical injuries, such as hip fractures, and in psychological effects, such as fearfulness (Van Leuven, 2010). Risk factors for assessment are summarized in Table 37-2.




Activities of Daily Living


Assessment of self-care needs and activities of daily living (ADLs) is essential for determining the patient’s potential for independence. Activity may be limited because of physical dysfunction or psychosocial impairment. Geriatric patients should be encouraged to be as independent as possible in self-care, although it is unrealistic to expect all patients to function independently, particularly in a hospital or long-term care setting. Conforming to the routines and procedures of the institutional environment fosters dependence in the patient. Because these behavioral deficits (excess disability) are associated with premature co-morbidity and mortality, institutional environments present the nurse with opportunities for creative intervention and care planning.


ADLs (e.g., bathing, dressing, eating, grooming, toileting) are concrete and task oriented. They provide an opportunity for purposeful nurse-patient interaction. Encouraging patients to be as independent as possible in performing their ADLs is important. This helps elders meet their needs for safety, security, personal space, self-esteem, autonomy, and personal identity.

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  4. Neurobiological Responses and Schizophrenia and Psychotic Disorders

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Geropsychiatric Nursing

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