In 2005, 2.6 million (13.1%) of the 20.3 million people in Australia were aged 65 years or older (Australian Institute of Health and Welfare (AIHW) 2006). The number of older adults in this population continues to grow, with 1.5% of the total population comprising older Australians aged 85 years or over. The proportion of older adults in New Zealand is similar. In 2002, in both New Zealand and Australia, 15% of males were over the age of sixty, as were 17% of New Zealand women and 18% of Australian women (NZ Statistics 2003a).

There are current trends for New Zealand Māori and Australian Aboriginal populations that healthcare practitioners should incorporate into their practice. For example, both groups have poor health as they age and a lower life expectancy than non-Māori and non-Aboriginal populations (Lewis 2002). The New Zealand Māori population is increasing as a proportion of the New Zealand population and the proportion of older Māori people is also increasing, with projections being that this group will increase from the current 4% of New Zealand’s older population to 11% in 2051 (Ministry of Health 2006). When making a diagnosis of mental illness, cultural concepts related to physical and mental wellbeing must be considered. The common cog nitive screening instruments such as the Mini-Mental State Examination (MMSE) (Folstein, Folstein & McHugh 1975) are of particular concern as they do not take into considera tion an individual’s educational attainment, language or culture. Cultural considerations must be taken into account when a mental health assessment is undertaken (see Chs 6 and 7 for more information).

Although older people may not necessarily be dependent on others, ageing brings with it an increase in certain disease processes (AIHW 2006). Mental illness is not, however, a normal occurrence of ageing, although the risk of developing mental illness does increase with age. In particular, risk factors for depression, such as loss and grief, social isolation, medical illness and disability and being a caregiver, are more common in older age (Murray et al 2006). The predicted increase in the older population is therefore expected to multiply the numbers of adults with mental illness (Bartels & Smyer 2002).

It is difficult to have a firm sense of how many older people have a mental illness as prevalence figures vary considerably according to the populations surveyed and the methodologies used (Lawlor & Radic 1994). In addition, there are also a number of negative stereotypical perceptions of age and older people that may inhibit the diagnosis and treatment of physical and mental illness. In 1969 Butler coined the term ‘ageism’ to define the systematic stereotyping of and discrimination against people because they are old (cited in Butler 1975). We have come to realise that ageism can apply to any age group, not just the aged. Thus, ageism has more recently been defined as discrimination against people on the grounds of their age alone, as a consequence of which stereotypical assumptions are made about how people are viewed throughout life (Behrens 1998).

Unfortunately, health professionals are not immune to ageist attitudes (Karlin et al 2005; Moyle 2003). Over the past decade a number of studies have investigated how healthcare professionals feel about caring for older people. Nursing students’ attitudes to older people have frequently been found to be negative (Martell 1999; Robinson & Cubit 2005; Stevens & Crouch 1992). Ageist views may in turn also affect the prevalence rates of mental illness in the older population through misdiagnosis or an unwillingness to diagnose individuals because they are seen as ‘old’.

Although the exact numbers of older people with mental disorders in the community are not known, we do know that there are higher rates of mental illness in populations who are institutionalised in residential-care settings (AIHW 1998; Ames 1994). Older people living alone are 3.3 times more likely to be depressed than those residing in a household with others (Schulman et al 2002).

It is important, however, not to stereotype older people as being unwell, and to remember that not all older adults require hospital services and assistance. Most older people in Australia and/or New Zealand live in their own home (91% of people over 65 years), and only 1 in 20 people aged 65 to 69 report that they require assistance with self-care activities (AIHW 1998). The need for assistance rises to 1 in 10 in those aged 70 to 79, and 1 in 3 in adults aged 80 or over (AIHW 1998).

Assessment of older people

All staff working with older people should begin by learning about normal older people, because the moment a problem appears, abnormality becomes the priority. The world is full of active and healthy older people and most older people do not require additional health and social support.

The main reasons for assessing older people are:

• to obtain a baseline assessment of function—this can assist in avoiding unrealistic goals

• to demonstrate positive changes to clients and to gather evidence for relatives, nurses and other health professionals

• for selection purposes (e.g. in research), to ensure that groups of people are of similar levels

• to evaluate a new approach, treatment program or service

• for legal purposes (e.g. complications following a head injury)

• to assist diagnosis and prognosis.

Most of the time nurses are involved with obtaining a baseline assessment of function and assisting with diagnosis and prognosis. However, when a client is experiencing psychological distress there may be little time to conduct a full assessment. The use of observation skills and a brief assessment of the client’s cognitive functioning through the use of the MMSE provide valuable baseline data on which to base subsequent observations and care (see Ch 11).

Ageism in assessment

Although there are many safe ways to investigate the reasons behind a change in behaviour and ability, conclusions are often drawn too quickly. It is too easy to assume, because a 70-year-old person fails to recognise familiar faces, and rambles and behaves strangely, that a dementing condition is the cause. There could be any number of reasons for this behaviour, from delirium to depression, and therefore it is important that nurses spend time with the client and their spouse or carers, to ensure a thorough and accurate assessment and to reduce the influence of ageist staff attitudes.

Critical thinking challenge 14.1

Reflect upon the nurse’s story ‘Dolores’. Consider why the conclusion of dementia was so readily presumed and how you might ensure, when assessing older clients, that this does not happen in practice.

Mental health disorders in the older population

Although a number of conditions—such as depression, anxiety disorders, suicide, substance misuse, delirium, dementia and schizophrenia—fall within the context of mental illness in old age, they do not occur because of ageing. It is predicted, however, that the incidence of such disorders may continue to increase as the population ages (Nadler-Moodie & Gold 2005). Each of these disorders is explored in the following sections.

Depression

The most common mental illness of old age is depression (Djernes 2006; Schulman et al 2002). Depression in older adults has often been found to be associated with vascular brain changes (Snowdon 2001).

Presentation

The presentation of depression (see Ch 16) in older age is often less obvious than in younger people as older people will often focus attention on their physical

Nurse’s story: Dolores

I was working in Accident and Emergency when Dolores was brought into the department in an unkempt and confused state. She was initially assumed by staff to be suffering from a dementing syndrome such as Alzheimer’s disease, as she was aged, incoherent and lay chanting on the stretcher.

On examination Dolores was found to be wearing several layers of clothing, each soiled with excrement. While one nurse undressed Dolores, another asked her husband Jack for information about her condition, how long she had been in this state and whether there was any underlying condition or medication that may have contributed to the situation. Jack indicated that his wife had been coherent, with clarity of thought, up until the previous week. She had not recently had an operation or ingested any medication or substance that might have caused a chemical-induced delirium.

The nurses were alerted to the possibility of a toxic delirium as Jack informed them that Dolores had a large chest wound and that she had not been receiving medical care. Under the many layers of clothing Dolores was found to have a fungating breast cancer. Early in her illness she had asked her elderly husband to nurse her at home and to promise that he would never take her to see a doctor. As her illness progressed she would not allow Jack to undress her, and as she became cold and soiled he placed new clothing over her existing clothing.

Dolores did not have Alzheimer’s disease. She was suffering from delirium as a result of a chemical imbalance due to her physical deterioration. Unfortunately, her condition deteriorated quickly and she survived only another five hours in hospital.

Nursing staff were distressed by the sight of Dolores in her many layers of wet and dirty clothing, and some staff felt that Jack had not cared for or about her. They assumed that a caring husband would have taken her for medical treatment earlier. But this assumption was incorrect—a neighbour and another relative spoke of Jack’s devotion to Dolores and his desire to carry out her every wish, even if it meant caring for her without medical and nursing assistance. It was during a debriefing, at the end of the day, that several staff came to recognise that despite their knowledge and education they had all too quickly jumped to an incorrect diagnosis because on initial observation Dolores was seen as being elderly and confused. It was timely to initiate continuing education sessions in the department to concentrate on such issues.

symptoms (see Ch 21) and are less likely to acknowledge feeling depressed (Snowdon 2001). Although they may exhibit the cardinal features of depression, such as lowered mood and loss of interest (DSM-IV-TR, American Psychiatric Association 2000), older people will often attribute these feelings to their physical condition rather than to a psychological state.

It is important to interview a spouse or carer as both a corroboration of the client’s history and to substantiate a professional assessment, as well as to gather additional information to assist in the assessment. A spouse or carer will commonly report changes that the individual has not recognised, such as social withdrawal, irritability, avoiding family and friends, poor hygiene and memory change. Losses such as status, income and bereavement can contribute to feelings of dejection (see Ch 10).

Diagnosing depression in an older population is compounded by the difficulty of differentiating it clinically from dementia and delirium (explored later in this chapter). Depression and dementia may both present with psychomotor slowing, apathy, impaired memory, fatigue, sleep disturbance and poor concentration.

Prevalence

There are varying accounts of the prevalence of depression among people over the age of sixty-five. Prevalence rates are estimated to be between 1.5% and 25% (Blazer 1997), with the higher rate being attributed to an insti tutionalised population (AIHW 1998). Variance in prevalence rates also results from epidemiologists generally only recording cases of major depression and dysthymia. They commonly have not included individuals with minor depression, which is common in old age as a result of a depression arising from functional decline and medical symptoms. Individuals with minor depression may have significant depressive symptoms but not fulfill all the DSM-IV-TR criteria for major depression or dysthymia (see Ch 16 for diagnostic criteria). Prevalence rates for depression are approximately 50% higher in women than in men (Bagley et al 2000).

Aetiology

There is a common perception that older people become depressed as a part of the normal ageing process. This is not so, but older people are vulnerable to developing a depressive illness because of age-related biochemical changes and psychological factors. Depression is frequently associated with many common medical con ditions found in later life such as stroke, cancer, myocardial infarction, diabetes, rheumatoid arthritis and Parkinson’s disease (Snowdon 2001). Psychological risk factors are bereavement, medications and losses related to physical illness, financial security, accommodation and independence (Bruce 2002; Norman & Redfern 1997; Snowdon 2001). Furthermore, older adults who are institutionalised face a number of changes to their normal routine as they often struggle to adjust to living in an environment where there are a lot of people, noise, rituals and habits that seem strange to them. Such factors may make them vulnerable to mental illness (Manion & Rantz 1995). See Chapter 9 for more information about mental health across the lifespan.

Assessment

It is essential that nurses are involved in the assessment of older clients and their psychosocial situations to assist in an early intervention nursing care plan. Assessment and management requires collaboration between health professionals who are skilled and educated in the care and management of older people with mental illness (Moyle & Evans 2007). It can be very difficult, especially with older clients, to distinguish between depression and dementia because both conditions share common features such as poor concentration, low mood and social isolation. To make this distinction even more difficult, depression often coexists with dementia. Furthermore, the diagnosis may be hindered where the person also has a physical illness which leads health professionals to believe that the person’s depressive symptoms are understandable given their physical status. Undiagnosed and untreated depression places the person at risk of mental suffering, poor physical health, social isolation and suicide.

A depression screening instrument such as the Geriatric Depression Scale (GDS) (Yesavage, Brink & Rose 1983) (see Table 14.1, overleaf) may assist in making the diagnosis, referral for treatment and in providing a baseline assessment against which to measure the effect of treatments. The GDS consists of thirty questions, which focus on the individual’s thoughts and feelings of depression experienced over the previous week. Unlike other screening instruments, the GDS avoids asking questions about physical symptoms, as this generation of people traditionally tends to concentrate on physical symptoms and avoid discussing emotional symptoms. They may also regard the presence of depressive symptoms as a part of their ageing process and neither ask for nor expect help with such symptoms. Where a differential diagnosis cannot be made, psychiatric consultation and/or a trial of antidepressant therapy may be warranted. While cognitive deficits are common in dementia and depression in older people, they will normally resolve with recovery from depression.

Table 14.1 Geriatric Depression Scale

1	Are you basically satisfied with your life?
2	Have you dropped many of your activities and interests?
3	Do you feel that your life is empty?
4	Do you often get bored?
5	Are you hopeful about the future?
6	Are you bothered by thoughts you can’t get out of your head?
7	Are you in good spirits most of the time?
8	Are you afraid that something bad is going to happen to you?
9	Do you feel happy most of the time?
10	Do you often feel helpless?
11	Do you often get restless and fidgety?
12	Do you prefer to stay at home, rather than going out and doing new things?
13	Do you frequently worry about the future?
14	Do you feel you have more problems with memory than most?
15	Do you think it is wonderful to be alive now?
16	Do you often feel downhearted and blue?
17	Do you feel pretty worthless the way you are now?
18	Do you worry a lot about the past?
19	Do you find life very exciting?
20	Is it hard for you to get started on new projects?
21	Do you feel full of energy?
22	Do you feel that your situation is hopeless?
23	Do you think that most people are better off than you are?
24	Do you frequently get upset over little things?
25	Do you frequently feel like crying?
26	Do you have trouble concentrating?
27	Do you enjoy getting up in the morning?
28	Do you prefer to avoid social gatherings?
29	Is it easy for you to make decisions?
30	Is your mind as clear as it used to be?

Scoring for the scale
Score one point for each of the answers given below:
1	no
2	yes
3	yes
4	yes
5	no
6	yes
7	no
8	yes
9	no
10	yes
11	yes
12	yes
13	yes
14	yes
15	no
16	yes
17	yes
18	yes
19	no
20	yes
21	no
22	yes
23	yes
24	yes
25	yes
26	yes
27	no
28	yes
29	no
30	no