ISSUES SPECIFIC TO THE ELDERLY
Kimberly S. McClane
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Describe the current demographics of the elderly population
2. Identify the impact of physical, emotional, and sociocultural issues influencing the mental health of the elderly patient
3. Discuss the most common mental health disorders associated with the elderly
4. Identify trends affecting mental health services provided to the elderly
5. Apply the nursing process from an interpersonal perspective for the care of an elderly patient with a mental health disorder
Activities of daily living
Quality of life
The elderly are considered to be individuals older than 65 years. In 2013, 44.7 million Americans were older than 65 years, reflecting an increase of 24.7% since the late 1990s. In the next decade, a further increase in growth of 38% is projected to occur. The current life expectancy in the United States is predicted to be 85.3 years for women and 82.4 years for men. In looking at the entire U.S. population, approximately 12.6% of individuals are 65 years of age or older and the numbers continue to rise. For the first time in history, there will be more individuals older than 65 years than in any other age group. Additionally, there will be more elderly Americans than there will be Americans in the workforce (Administration on Aging [AoAna], 2014).
The World Health Organization (WHO, n.d.) estimates that 20% of all adults 60 years of age and older suffer from a mental or neurological health disorder that negatively impacts their quality of life (QOL). This does not include headaches (migraines) or depression.
This chapter addresses the mental health issues related to the elderly. It describes some of the current statistics related to the elderly population and factors impacting the mental health of the elderly. The chapter reviews the most common mental health disorders affecting the elderly population and trends affecting care delivery. The chapter concludes by applying the nursing process from an interpersonal perspective to the care of an elderly patient with a mental health disorder.
OVERVIEW OF THE ELDERLY POPULATION
In 2013, 21.2% of individuals were members of racial or ethnic minority populations: 8.6% were African Americans, 3.9% were Asian or Pacific Islander, 0.5% were Native Americans, 0.1% were Native Hawaiian/Pacific Islander, and 0.7% identified themselves as being of two or more races. Persons of Hispanic origin (who may be of any race) represented 7.5% of the older population (AoAna, 2014). The remaining 77.7% were identified as Caucasian (U.S. Census Bureau, 2015).
Quality of Life
Another frequent indicator that is used to measure the aging individual’s mental and physical health is QUALITY OF LIFE. QOL, used as an indicator of health by the WHO, is defined as “a state of complete physical, mental, and social well-being and not the absence of disease or infirmity” (WHO, 2014, p. 1). This reflects the strong association of physical and mental health in the aging individual. Mental health as a component of overall health needs to be recognized and treated as aggressively as any physical diagnosis in the aging individual.
In 2014, the WHO (2014) reframed the international mental health definition to be:
Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.
The positive dimension of mental health is stressed in WHO’s definition of health as contained in its constitution:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (p. 1)
Active aging is the process by which the aging individual is an active participant in society. This is not solely defined by physical abilities, but rather continence of practicing in their social, spiritual, cultural, and civic duties. These skills can be translated into volunteering, teaching, and family structure. This active lifestyle significantly influences a positive QOL in the elderly (WHO, n.d.)
Quality of life is a key indicator of an individual’s overall health, but especially the overall health of an elderly individual.
Providing adequate care to those older than 65 years requires identification of funding sources for mental health issues. The primary health insurance provider for many aging Americans is Medicare (Medicare & You, 2015). Medicare consists of four components for reimbursement. They are:
Medicare Part A: This covers partial reimbursement to the patient during hospitalization including room, services, and treatments.
Medicare Part B: This segment of the plan covers outpatient treatment, supplies, or other services. Some of these services include a psychiatrist or other doctor; clinical psychologist, social worker, or nurse specialist; nurse practitioner; physician’s assistant; group or individual therapy; counseling services; medication; and diagnostic services.
Medicare Part C: This addition to governmental Medicare provides the client with the ability to purchase an insurance choice that covers more than the 80% that Medicare reimburses. The plan is based on an approved health maintenance organization (HMO) or a preferred physician organization (PPO) and includes all of parts A, B, and D. Some may offer other additional benefits and services.
Medicare Part D: This section is the drug reimbursement portion of the plan, which is based on a frequently updated national formulary (Medicare & You, 2015).
FACTORS INFLUENCING MENTAL HEALTH IN THE AGING POPULATION
Merck (2015) has stated that, on average, individuals older than 65 years have at least six disorders, and their primary physician may be unaware of them. These disorders significantly impact their behavior, socialization, and mood. Factors specific to the aging population are addressed here.
Multiple physical changes can impair the mental health of the aging individual. These changes include:
Hypothermia or hyperthermia
Infection and sepsis
Sensory changes (Gallo & Bogner, 2006)
The Maryland Coalition of Mental Health and Aging (MCMHA, n.d.) identified the biological changes related to:
A decrease in the number and the mass of nerve cells
Changes in nerve conduction and alteration of the senses
Increased rigidity, function, and decreased organ capacity that alter the function of one or more organs
In many instances, individuals who are older than 65 years accept these physical changes as normal changes related to the aging process. However, these age-related changes, even if corrected, can negatively influence the individual’s QOL. For example, a loss of physical function and mobility can lead to a loss of independence. This loss of independence can lead to social withdrawal, self-isolation, and anxiety or depression (Gagliardi, 2006).
Typically, physical changes in the elderly are dismissed as normal, age-related changes. However, they can significantly impact the person’s mental health, leading to social isolation, anxiety, and depression.
Merck Manual Professional Version (2015) reports that an average individual older than 65 years has six diagnosable disorders. Having these conditions can be the basis of a multiple system disorder with an organ system influencing another. These may be sensory, physical, or mental components. Another issue complicating these issues is social disadvantage relating to the client’s socialization, poverty, functional disorders, and economic status. There is a strong association between chronic illness and mental health, with chronic illnesses often leading to depression and other mental health problems (Chowdhury & Rasani, 2008).
Patients and family need education about the risk of depression or altered mental health issues with chronic illness. The illness itself may lead to problems, for example, decreased mobility leading to social isolation, withdrawal, and depression or cognitive changes interfering with the patient’s ability to function independently. Ultimately, these changes can impact the patient’s coping ability and self-esteem.
Additionally, prescribed or over-the-counter medications and herbs may produce side effects, such as confusion and disorientation, or interact with one another, predisposing the patient to an increased risk of mental health problems, such as depression or anxiety. The patient and family also need to be aware that a physical illness may exacerbate a previous mental health disorder and that a previous mental health disorder may worsen a physical illness. Thus, if a patient and family have adequate knowledge and understanding of the signs or changes that can be associated with mental health disorders, early interventions can be implemented, thereby diminishing the overall impact (Kramer, Beaudin, & Thrush, 2005).
Pain has been designated as the fifth vital sign (in addition to the four vital signs of temperature, pulse, respirations, and blood pressure). The estimated prevalence of pain ranges from 36% to 88% for those in the age group of 65 years and more. Pain related to bone and joint problems, chronic pain related to chronic illness or trauma experienced before age 65 years, or acute illnesses are frequently underdiagnosed and undertreated. Self-reporting of pain may be viewed as drug-seeking behavior or minimized by the aging individual’s primary care practitioner (PCP; Pratt et al., 2007).
The diagnosis of chronic pain in the elderly is associated with actual or potential damage to tissues/bones lasting more than 3 months, which may impair function and mobility and lead to social isolation, decreased participation in previously enjoyed activities, and increased risk of suicide (Kaye, Baluch, & Scott, 2010).
Additionally, the increased cost of health care, decreased QOL, and possible early retirement that could negatively influence finances are other concerns associated with pain. Moreover, chronic, unresolved pain has been associated with an increased risk of a mental health disorder such as depression, suicide, or anxiety (Blay, Andreoli, Dewey, & Gastal, 2007).
When pain occurs, medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used. However, these medications place the aging adult at risk of adverse drug reactions or drug–drug interactions. Opioids, commonly prescribed for pain relief, are not first-line choices for aging patients because of the potential for diminished cognition, mood disturbances, insomnia, constipation, and addiction.
The ultimate goal is to maximize pain relief with a minimum of side effects. For the elderly, treatment should include physical therapy or the addition of complementary and alternative therapies. Both patient and caregivers need education about pain management and how it might impact the older adult. Prescribing physical rehabilitation may be useful in increasing independence and function. Pain-related studies have shown a strong link among pain, aging, depression, and insomnia, necessitating that all these should be addressed simultaneously (Kaye et al., 2010; Merck & Co., 2006d).
The presence of pain, its effect on functioning, and the associated treatment can predispose the elderly patient to mental health problems such as changes in cognition, mood, and sleep patterns.
INSOMNIA is a symptom of a disease process and not a diagnosis. It is defined as an inability to initiate or maintain sleep and is classified as transient or short term (once to twice a week for 4 to 6 weeks); intermittent (varying over a time with no set pattern); and chronic (occurring two or more times a week for more than 1 month).
The aging individual may exhibit signs and symptoms of insomnia such as sleeping for short periods during the night, sleeping during times of normal social activities, arising early in the morning while others sleep, and experiencing daytime sleepiness. Other indicators may include increased irritability, decreased mental function, changes in short-term memory, and the need for frequent and lengthy naps during the day (Ancoli-Israel & Cooke, 2005).
Insomnia in the aging adult can be caused by several factors that can occur concomitantly. Examples of causes of chronic insomnia issues are highlighted in Box 23-1.
Medications such as antidepressants, antihistamines, antihypertensive agents, nasal decongestants, chemotherapeutic agents, and opioids can lead to insomnia. In addition, decreased melatonin, poor sleep hygiene, and lack of sunlight are other causes. Sunlight has been associated with insomnia in institutionalized populations who are not exposed to sunlight (Medical News Today, 2005; Merck & Co., 2006e).
Measures to combat insomnia include establishing a consistent bedtime and discontinuing or limiting napping during the day, increasing daily activity levels, limiting caffeine or other stimulants, using the bed for only sex and sleep, avoiding large meals close to bedtime, and not obsessing about falling asleep. If the individual does not fall asleep within one-half hour, meditation or other relaxing activities should be considered. Depending on the individual’s physical health status, a sleep apnea study may be warranted (Merck & Co., 2008).
BOX 23-1: CAUSES OF CHRONIC INSOMNIA
• Depression (the most common cause)
• Chronic pain
• Kidney disease
• Restless legs syndrome
• Heart failure
• Parkinson’s disease
• Sleep apnea
• Benign prostrate hypertrophy
• Anxiety about not being able to sleep
• Consuming alcohol before bedtime
• Consuming excessive amounts of caffeine
• Smoking cigarettes before bedtime
• Excessive napping in the afternoon or evening
Often, insomnia is treated with medication, such as sedatives and hypnotics or antianxiety agents, before bedtime. Unfortunately, these drugs pose a risk for older adults and for people with breathing problems because they suppress the areas of the brain that control breathing. In addition, prescription insomnia medications are often habit forming, although their degree of addiction varies from person to person (Fetveit, 2009). In addition, herbal remedies may be used. Valerian root and melatonin are two common ones.
As with any medications used by older adults, the chronic use of drugs to promote sleep can produce undesirable side effects, including impaired memory and alertness, incontinence, daytime sleepiness, and alteration in metabolic or electrolyte imbalances. These side effects can exacerbate the patient’s existing problems or create new ones.
Skilled nursing facilities frequently provide sleeping medications for their residents. Studies show that the use of sleeping medications increases the risk of falls. In addition, insomnia is increased in skilled nursing facilities due to the need for lights to be on at various locations and a louder-than-normal environment at night. Recent studies have shown that there is a decrease in insomnia in many of these residents if they are exposed to short periods of sunlight several times a week (Gobert & D’hoore, 2005). This exposure to natural light helps in the production of the necessary vitamins and chemoreceptors that enhance sleep.
Disabilities and Functional Decline
Preexisting health issues are often present before the age of 65 years. The aging person will bring his or her life’s health histories, behaviors, and/or handicaps and disabilities to the need for health care. These comorbid conditions can be very significant in the QOL and mental health of the elderly. Thus, the many changes that occur with aging and the preexisting conditions together can significantly influence the overall health of the older person.
Individuals younger than 65 years usually have preexisting conditions that can be associated with a functional disability. Aging individual’s functional decline may be attributed not only to previous functional disabilities but also to the accumulation of chronic diseases, and it is dynamic and may or may not be episodic (Colon-Emeric, Whitson, Pavon, & Hoenig, 2013).
Ferranti, Pasini, Murphy, Leo-Summers, and Gill (2015) have also identified that in an elderly client, who has a preexisting disability, at the outcome of a diagnosis of a critical disease there are changes in behavior and function. Another comorbidity that has significant impact is depression.
In another study, it was recognized that functional decline may be episodic, with the acceptance of intermittent versus chronic function. One important function that is associated with decline can be correlated with personal and residential independence (Colon-Emeric et al., 2013). Application of “an algorithm for evaluating new disability in an older adult” (p. 390) can be a potential method to evaluate the elder client.
Stress and Change
Many individuals who retire make plans for their finances, residence, activities, social and community connections, and resources. However, as one ages, major stresses may arise leading to altered mental health, especially depression or anxiety. Research has shown that increased stress in an aging individual increases the physical and mental aging processes. In addition, studies have shown that prolonged stress has been associated with decreased immune function and altered health status (MCMHA, n.d.; McClane, 2005).
Some of the identified situations associated with stress include:
Caregiving for another person
Increased leisure or unstructured time
Reliance on others
Loss of loved ones
Pain or disability
Relocation or housing changes
Negotiating new systems (i.e., health care benefits)
Sensory decline (hearing and vision)
Change in appearance
Cultural emphasis on the value of youth
Two of the most common indicators of increased stress in the aging are social isolation and depression, viewed as an inability to manage stress in changed life circumstances. The aging individual may exhibit physical signs and symptoms such as fatigue, headaches, cold feet and hands, neck or back pain, and altered gastrointestinal functions. Many would consider these normal when experiencing stress. However, if these are present more than 2 to 4 weeks, further evaluation is necessary.
Loss has a major influence on the mental health of the older adults. The loss of a spouse is considered a major risk factor for depression in the elderly. Other losses exerting an influence include loss of siblings, friends, or family pets. This loss can coexist with a change in living arrangements or increased health problems. Moreover, the older adult may be experiencing a loss of mobility, loss of sensory function, or loss of bladder control (incontinence), leading to feelings of decreased self-worth and depression (Chen & Fu, 2008). Any single loss or combination of losses can lead to social isolation and subsequently depression.
Elderly individuals experience a wide range of losses, both physical and emotional, that can occur as single or multiple events, placing them at risk of decreased self-esteem and depression.
The relationship, or lack thereof, with family is a factor that influences the quality of an elder’s mental health. Factors such as loss of communication, lack of understanding between the elder and family members, an increased need for care of the elder that is not easily available, or lack of knowledge about conditions affecting the elderly can contribute to mental health problems. Historically, the eldest daughter or female relative assumed the caregiving responsibility for aging family members. However, today, with many families depending on dual incomes, the care responsibilities may fall on adolescents or ancillary family members. This situation, coupled with the factors mentioned, can negatively influence the mental health of the elder as well as cause disruptions in the household and the family unit itself (Ron, 2008).
Caregiver stress with associated depression or anxiety often occurs when a family member, often a partner, provides care for a spouse or significant other. Aside from the impact of the stress of the disorder on the patient’s functioning, this caring role also takes a physical toll on the caregiver. The lack of access to care, underutilization of available resources, social isolation, or fear of separation can result in significant strain on the caregiver. Additionally, the caregiver may be unable to fully or safely provide care for the patient, creating a dangerous physical environment for both the patient and the caregiver (Son, Erno, Feemia, Zarit, & Stephens, 2007).
In 2015, Ejem, Drentea, and Olivio found an increase in mental health issues in the care recipient as well as the care provider. There were 1,340 caregiver/receiver dyads and there was a significant increase in both experiencing increased emotional stress and depression.
Family or caregiver coping can be enhanced by a referral to support groups for caregiving of specific diseases. As an example of services available, the California Department on Aging (CDA, 2015) provides family and individual agencies including the Family Caregiver Support Program, Community-Based Adult Services, Nutritional Services, and a Multipurpose Senior Services Program.
Peplau defined LONELINESS as “an unnoticed inability to do anything while alone” (1988, p. 256). The prevalence of loneliness in individuals older than 65 years has been estimated to range from 5% to 26%. Loneliness is an individual response to unfulfilled needs for intimacy or social contacts. Two forms of loneliness have been defined. The first, SOCIAL LONELINESS, is related to a loss of contact with peers, friends, or groups that have shared and supported the needs of the elderly individual. The second, EMOTIONAL LONELINESS, is associated with loss of intimacy with a partner, family member, or friend who can no longer support the emotional needs of the elder. Both of these classifications can be experienced alone or in conjunction with one another. There is no defining period for how long loneliness will last.
Wu and Penning (2015) investigated if immigration from other countries increases the risk of loneliness during aging. In a sample of more than 10,000 participants, immigrants of age 60 to 80 years had a higher incidence of loneliness than naturalized elders. There was no significant change in clients older than 80 years. This can be conjectured to be from neurosensory changes and impaired cognition.
Social loneliness has been associated with a loss of connectedness to friends, peers, family, or social activities within groups that supported the elder in his or her declining age in many facets of life. A major risk for social loneliness includes relocation of the person’s residence, either geographically or to a new housing environment. Individuals who have relocated to assisted living or skilled nursing facilities often face this issue. Although they may have increased contact with other residents, this contact does not translate into the quality of relationships previously experienced (Drageset, 2002).
Social loneliness, according to Gierveld and Tilburg (2006), is an indicator of well-being and the feeling of loss in intimate relations or a previous social network. They devised both a one-item De Jong Gierveld Loneliness Scale and a six-question version. This questionnaire is easily administered and provides important information on the status of a client, especially following relocation.
Emotional loneliness is experienced when an individual or group who provided intimacy and support to the elder no longer does so. As one ages, the loss of a partner, friends, or family increases while the ability to create new relationships decreases. The loss of these bonds and support systems negatively impacts the elderly. One specific group of elders that has reported slowly but increasing perceptions of loneliness is caregivers. The need to care for a partner or family member causes a loss of opportunities for socialization, creating social isolation, while the declining health of the individual in need of care may also reflect a decline in emotional support, creating emotional loneliness (Drageset, 2002).
Loneliness has a strong correlation with declining mental health of the aging individual, most commonly depression. Depression is a mental state associated with loneliness. However, not all elders experiencing depression have associated feelings of loneliness. One study reported that the risk of mortality was 2.1 times higher for those experiencing loneliness with depression (Stek et al., 2005). This study also identified other health risks as being associated with loneliness and depression including increased cognitive impairment, insomnia, impaired nutrition, hypertension, and other cardiac risk factors. An earlier study (Weeks, Michela, Peplau, & Bragg, 1990) correlated a relationship between loneliness and depression. However, this study defined both as separate mental health issues. More recently, O’Luanaigh and Lawlor (2008) discussed the connection between mental health and loneliness in the elderly, exploring physical responses to loneliness, including hypertension, insomnia, abnormal stress responses, and altered nutrition. Thus, the issue of loneliness in the elderly can have an associated morbidity to other elder health issues.
The assessment of loneliness as depression is often misdiagnosed, causing decreased QOL for the patient. Assessment can be confirmed by self-reporting and use of multiple assessment tools designed to improve the recognition of loneliness. The UCLA Loneliness Scale is one of the most commonly used tools. A knowledge base in assessing and then following through and providing resources for the lonely elder is important (Cornell & Waite, 2009).
Using the UCLA Loneliness Scale, Zebhauser et al. (2015) found that 70% of the elderly living alone were not lonely. Their conclusions indicated that loneliness was not reflected by income and level of education, and age-related limitations were not components of loneliness. The presence of a stable and functional social network was significant in determining their mood states and loneliness.
The treatment for loneliness is often based on other mental health symptoms such as anxiety or depression. A primary intervention for loneliness in the elderly is to expand contacts and relationships with family and close friends (Petigrew & Roberts, 2008). It was noted that the quality of social interactions rather than the quantity of interactions is important (Magai, Consedine, Fiori, & King, 2008). Improved life satisfaction also occurred in aging individuals with loneliness when they were introduced to the Internet (Patel, 2007). Electronic communication, especially with distant family and friends, has been associated with decreased levels of loneliness.
Jones, Ashurst, Atkey, and Duffy (2015) found that the use of the Internet reduced loneliness and improved mental health well-being. Once proficient on the computer, their next reported action was to become a tutor for other aging individuals. Senior Living.Org (2011) identified frequently used websites for the aging client. These include aging well, AARP, travel, health, technology, and humor. In assessing the elderly and their Internet use, ask for the sites/topics they frequently visit and evaluate if these are appropriate sites for the client. You can also refer the client to the Federal Bureau of Investigation (FBI, n.d.) for information on potential scams and how to avoid or report them to the FBI.
Loneliness, an individual response to unfulfilled needs for intimacy or social contacts, occurs in two forms: social loneliness, which is related to a loss of contact with peers, friends, or groups who have shared and supported the elderly individual’s social needs; and emotional loneliness, which is associated with the loss of intimacy with a partner, family member, or friend who can no longer support the elderly individual’s emotional needs.
Abuse and Neglect
The American Psychiatric Association (2015) estimated that there were 4 million cases of elder abuse or neglect in 2014, and for each identified case of neglect 23 cases go unrecorded. This rate may continue to increase with the aging population growth, with increased frailty and cognitive disorders.
Abuse and neglect can be inflicted on an aging individual or be self-imposed. The abuse patterns may involve a family member or caregiver who has some influence in the elder’s daily life. Control is the overall issue, which can lead to depression, anxiety, and potentially life-threatening physical injuries. Table 23-1 summarizes the five classifications of abuse that significantly impact the aging individual’s mental health. However, all forms of elder abuse can be very threatening and frightening to the abused (Merck & Co., 2006a). (See Chapter 24 for a more in-depth discussion about elder abuse.)
TYPE OF ABUSE
IMPLICATIONS FOR THE AGING INDIVIDUAL
Result of physical force and violence leading to physical illness or trauma in the elder.
Includes bodily injury and pain, physical impairment, or inappropriate restraints (chemical or physical).
No clear indicator of an elder being more or less at risk for this type of abuse.
Perpetrators often associated with unmarried family members or caregivers living with the victim and relying on the elder’s home and financial support; frequently substance abuse problem involved.
Careful assessment of elderly patients for signs of unexplained injury or scars, frequent visits to the urgent care or emergency department.
Any physical contact to which an individual does not consent.
Includes rape, molestation, insertion of foreign objects, or any other unwanted sexual contact.
Domestic violence if occurring between marital partners.
Those at risk: aging women, individuals unable to provide consent due to mental impairment, individuals who have poor social skills or are socially isolated, individuals residing in skilled care facilities (often at a higher risk for sexual abuse than those residing in family residences) (Edwards, 2005).
Assessment of potential victims for any signs of bruises, injuries, or bleeding from the genitalia, inner thighs, or breast area; inability to walk or sit comfortably; frequent urinary tract infections or sexually transmitted diseases (NCPEA, 2008).
Intentional infliction of mental or emotional anguish because of threats, humiliations, or other verbal or nonverbal conduct.
Perpetrators similar to those of physical abuse, as they may rely heavily on the resources of the aged.
Indicators difficult to identify as they may result in a more rapid decline in the elder, such as weight loss, insomnia, or other indicators of stress.
Failure of an individual to receive his or her daily needs and security.
Active neglect is purposeful and calculated. Passive neglect is the result of the inability of the caregiver to provide the daily needs; possibly related to knowledge deficit, personal illness or disability, stress, or lack of resources.
Victim is dependent on assistance because of mental or physical disabilities; individuals requiring a high level of care.
Possible substance abuse.
Key indicators: poor nutrition; dehydration; unclean, disheveled appearance; and unhealed lesions or decubitus ulcers (NCPEA, 2008).
Individual as the victim.
Socially isolated, living in an unkempt environment, possibly affecting members of the surrounding community.
Indicators: hoarding; keeping large volumes of paper, food items, or large numbers of domestic animals.
Refusal of assistance from family and outside agencies.
Social services often are required to remove elder from personal environment—the last alternative for the elder, as reports have shown a very low survival rate of 6 months following the change (Dong et al., 2009).