Upon completion of this chapter, the reader will be able to: 1. Discuss factors contributing to mental health and wellness in late life. 2. Discuss the effect of chronic mental health problems on individuals as they age. 3. List symptoms of anxiety and depression in older adults, and discuss assessment, treatment, and nursing responses. 4. Recognize elders who are at risk for suicide, and utilize appropriate techniques for suicide assessment and interventions. 5. Specify several indications of substance abuse in elders, and discuss appropriate nursing responses. 6. Evaluate interventions aimed at promoting mental health and wellness in older adults. 7. Develop an individualized nursing plan of care for an older person with depression and bipolar disorder. Erikson et al. (1986) proposed that autonomy, intimacy, generativity, and integrity were all aspects of mentally healthy adult adaptation. 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 (Chapter 6). 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 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 when compared to nondepressed older adults, regardless of chronic morbidity (Evans, 2008; Shellman et al., 2007). The most prevalent mental health problems in late life are anxiety, severe cognitive impairment, and mood disorders. Alcohol abuse and dependence is also a growing concern among older adults. The focus of this chapter is on the differing presentation of mental health disturbances that may occur in older adults and the nursing responses important in maintaining the mental health and self-esteem 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 19. To understand mental health and mental health disorders in aging, it is important to be aware of stressors and their effect on the functioning of older people. The experience of stress is an internal state accompanying threats to self. Healthy stress levels motivate one toward growth, whereas stress overload diminishes one’s ability to cope effectively. As a person ages, many situations and conditions occur that may create disruptions in daily life and drain one’s inner resources or create the need for new and unfamiliar coping strategies. The narrowing range of biopsychosocial homeostatic resilience and changing environmental needs as one ages may produce a stress overload (Evans, 2008). Much remains unknown about the connection between emotions and health and illness, but it is known that the mind and body are integrated and cannot be approached as separate entities. Stress may reduce one’s coping ability and negatively impact neuroendocrine responses that ultimately impair immune function, and older adults show greater immunological impairments associated with distress or depression (Kolanowski and Piven, 2006). Research on psychoneuroimmunology has explored the relationship between psychological stress and various health conditions such as cardiovascular disease, type 2 diabetes, certain cancers, Alzheimer’s disease, frailty, and functional decline. The production of proinflammatory cytokines influencing these and other conditions can be directly stimulated by negative emotions and stressful experiences. Older people often experience multiple, simultaneous stressors (Box 18-1). Some older people are in a chronic state of grief because new losses occur before prior ones are fully resolved; stress then becomes a constant state of being. Stress tolerance is variable and based on current and ongoing stressors, health, as well as coping ability. For example, if an elder has lost a significant person in the previous year, the grief may be manageable. If he or she has lost a significant person and developed painful, chronic health problems, the consequences may be quite different and can cause stress overload. In the older adult, stress may appear as a cognitive impairment or behavior change that will be alleviated as the stress is reduced to the parameters of the individual’s adaptability. Regardless of whether stress is physical or emotional, older people will require more time to recover or return to prestress levels than younger people. Researchers concerned with the effects of stress in the lives of older people have examined many moderating variables and have concluded that cognitive style, coping strategies, social resources (social support, economic resources), personal efficacy, and personality characteristics are all significant to stress management. Social relationships and social support are particularly salient to stress management and coping. Social relationships may reduce stress and boost the immune system by providing resources (information, emotional, or tangible) that promote adaptive behavioral or neuroendocrine responses to acute or chronic stressors (Holt-Lunstad et al., 2010). In fact, individuals with adequate social relationships have a 50% greater likelihood of survival compared to those with poor or insufficient social relationships, an effect comparable with quitting smoking and exceeding many known risk factors for mortality (e.g., obesity, physical inactivity). Some factors that influence one’s ability to manage stress are presented in Box 18-2. Resilience, hardiness, and resourcefulness have been associated with coping with stress and crisis and may explain the ability of some individuals to withstand stress. Kolanowski and Piven (2006) noted that while we know the qualities associated with resilience, hardiness, and resourcefulness, it is not clear if they are personality traits or processes by which the individual responds to the environment. Further research is needed to more fully understand these concepts and their relationship to positive outcomes. The quality of hardiness is seen to have a protective influence against illness during stress (Kobasa, 1979). The cornerstones of hardiness are control, commitment, and challenge (Kobasa, 1979). Central to hardiness is the viewpoint that stress is a decision-making challenge and that meaning comes from making decisions. Stressful situations are seen as opportunities for growth. Life goals and a sense of purpose or meaning undergird hardiness. Factors associated with hardiness are social connectedness, confronting problems head-on, extending oneself to others, and spiritual grounding (Vance et al., 2008). Research suggests that individuals with high levels of hardiness characteristics display higher levels of physical and mental health and age successfully. Nurses can identify hardiness characteristics in older individuals and encourage development of new hardiness resources. Vance and colleagues (2008) provide an example of an individualized program of hardiness training that focuses on specific ways to learn coping strategies for dealing with obstacles and responding with positive adaptive behaviors. Resilience is a concept closely related to hardiness that is associated with coping with stress and crisis. Resilience is defined as “flourishing despite adversity” (Hildon et al., 2009, p. 36). The process of resilience is characterized by successfully adapting to difficult and challenging life experiences, especially those that are highly stressful or traumatic. Resilient people “bend rather than break” during stressful conditions and are able to return to adequate (and sometimes better) functioning after stress (“bouncing back”). Characteristics associated with resilience include: positive interpersonal relationships; a willingness to extend oneself to others; optimistic or positive affect; keeping things in perspective; setting goals and taking steps to achieve these goals; high self-esteem and self-efficacy; determination; a sense of purpose in life; creativity; humor; and a sense of curiosity. These are considered personality traits as well as ways of responding to difficult events that have been learned and developed over time (Resnick & Inguito, 2010). Older people may demonstrate greater resilience and ability to maintain a positive emotional state under stress than younger individuals. Resilience in older adults has been associated with management of chronic pain, better function, mood, enhanced cognitive capacity, quality of life, and an overall adjustment to the stressors associated with aging. Resnick & Inguito (2010) suggest that understanding and evaluating resilience are important “so that individuals with low resilience can be identified and appropriate interventions implemented to help them overcome challenges associated with aging and engage in behaviors associated with successful aging such as exercise” (p. 2). Professional interventions and supportive services can enhance resilience. Rogerson and Emes (2008) explored the concept of resilience among frail community-dwelling older adults who participated in an adult day program. Participants identified the resources provided by the adult day program as major contributors to resilience. Resilience came in the form of functional fitness through regular physical activity, enhancing the size and quality of the social support network, and linking the participant to community resources. Resourcefulness has also been linked to positive coping with life stressors. Resourcefulness is characterized as a “cognitive behavioral repertoire of self-control skills accompanied by a belief in one’s ability to cope effectively with adversity” (Zauszniewski et al., 2007). Zauszniewski and colleagues describe a study investigating the effect of resourcefulness training (RT) for chronically ill older adults residing in assisted living facilities. RT teaches and reinforces the cognitive and behavioral skills that strengthen personal and social resourcefulness. Personal resourcefulness skills include coping strategies, problem-solving, positive self-talk, priority setting, and decision-making. Social resourcefulness skills involve assisting older people to make decisions about when and how to seek help from formal and informal sources as well as strategies to strengthen internal (self-help) and external (help-seeking) resources for maintenance of healthy functioning. Results of the study suggest that teaching resourcefulness skills is a nursing intervention that may enhance positive affect and cognition, promote independence and improve function in older adults (Zauszniewski et al., 2007). Coping is a complex developmental and multifaceted process that develops over the lifespan. Some experts suggest that coping may be less effective in older individuals because of increased vulnerability to health problems and other stressors. Others postulate that older adults may use fewer coping styles but are just as skilled in coping as middle-aged individuals. Coping may also contribute more to the health of older than younger individuals because older adults utilize it to optimize their resources. Further research with older adults is needed, but coping “may be an important component of optimal aging” (Yancura & Aldwin, 2008, p. 11). Box 18-3 presents some coping strategies of older adults. Coping strategies are the stabilizing factors that help individuals maintain psychosocial balance during stressful periods. Coping strategies involve the identification, coordination, and appropriate use of personal and environmental resources to deal with stressors (Demers et al., 2009). Coping is a process that begins with appraisal of the stressor’s potential impact and the tools available for dealing with it. The appraisal of the stressor as benign, threat, harm/loss, or challenge guides the choice of coping strategies (Lazarus & Folkman, 1984; Moos et al., 2006; Yancura & Aldwin, 2008). Individuals use a mixture of coping strategies depending on the situation and their skills and experience. Individuals with more personal (cognition) and environmental resources (social network) use more varied coping strategies, and this may be related to longer life expectancy (Demers et al., 2009). Types of coping strategies and their descriptions are presented in Box 18-4. 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. General issues in the psychosocial assessment of older adults involve distinguishing among normal, idiosyncratic, and diverse characteristics of aging and pathological conditions. Baseline data is often lacking from an individual’s earlier years. Using standardized tools and functional assessment is valuable, but the data will be meaningless unless placed in the context of the patient’s early life and hopes and expectations for the future. An understanding of past and present history, the person’s coping ability, social support, and the effect of life events are all part of a holistic assessment. Careful listening to the person’s life story, an appreciation of their strengths, and coming to know them in their uniqueness is the cornerstone of assessment (Chapter 6). Assessment of mental health includes examination for cognitive function or impairment and the specific conditions of anxiety and adjustment reactions, depression, paranoia, substance abuse, and suicidal risk. Assessment of mental health must also focus on social intactness and affectual responses appropriate to the situation. Attention span, concentration, intelligence, judgment, learning ability, memory, orientation, perception, problem solving, psychomotor ability, and reaction time are assessed in relation to cognitive intactness and must be considered when making a psychological assessment. Assessment includes specific processes that are intact, as well as those that are diminished or compromised. Assessment for specific mental health concerns is discussed throughout this chapter and in Chapter 7. Assessment of cognitive function is discussed in Chapters 7 and 19. 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, 2010). 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. With the passage of the mental health parity legislation in July 2008, Medicare’s discriminatory practice of imposing a 50% coinsurance requirement for outpatient mental health services instead of the 20% required for other medical services was changed. The reduction of this coinsurance to 20% over a period of six years will bring payments for mental health care in line with those required for all other Medicare Part B services (Centers for Medicare and Medicaid services, 2010). The passage of this legislation will significantly improve the lives of older adults by providing them with improved access to mental health care (American Association for Geriatric Psychiatry, 2008). A 190-day lifetime limit still remains on treatment in inpatient mental health facilities. Psychiatric services may be provided by a psychiatrist, psychologist, licensed clinical social worker, nurse practitioner, or geropsychiatric clinical nurse specialist. New models of providing mental health care in primary care settings, many utilizing advanced practice nurses with geropsychiatric preparation, show promise for improving access and outcomes (Arean et al., 2005; Callahan et al., 2005). However, as Evans (2008) notes, nurses will need to assist older people to access appropriate mental health services and understand reimbursement issues. 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. Advanced practice psychiatric nursing consultation is an important and effective service in acute care settings. 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 dementia admissions (Splete, 2009). Medicaid beneficiaries with schizophrenia between 40 and 64 years of age are four times more likely to be admitted to a nursing home compared with Medicaid beneficiaries in the same group without a mental illness (Grabowski et al., 2010). 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. Residential care/assisted living facilities also have a high proportion of residents with mental health disorders. In one of the few studies of mental health in this setting, Gruber-Baldini and colleagues (2004) reported that more than 50% of residents were taking a psychotropic medication and 66% had some mental health problem indicator (medication, depression, psychosis, or other psychiatric illness). Older adults in home and community settings also experience mental health concerns and inadequate treatment. “Family caregivers of depressed home care recipients are likely to be depressed as well with 18.8% reporting high levels of distress (Ayalon et al., 2010, p. 515). 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. Psychiatric services in nursing homes, when they are available, are commonly provided by psychiatric consultants who are not full-time staff members and are inadequate to meet the needs of residents and staff. 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. 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 (Kolanowski & Piven, 2006). Disparities affecting mental health care in diverse populations include less access to mental health services, poorer quality of care, and underrepresentation in research. Racially, culturally, and ethnically diverse older adults are more likely than other ethnic groups to be underdiagnosed and undertreated for depression. Some identified barriers to the use of services include stigma about a mental health diagnosis, co-morbid medical problems, clinical presentation of somatization, a lack of bilingual staff, a lack of awareness of the existence of services, and difficulties with the patient-provider relationship (Ortiz and Romero, 2008; Shellman et al., 2007). Box 18-5 presents research findings on older African Americans’ beliefs and attitudes toward depression. Chapter 5 discusses culture and aging in depth. 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. More data is needed on the mental health needs of geriatric and ethnic minority populations, and, in recognition of this need, a follow-up study to the IOM (2008) study, The Re-tooling for an Aging America: Building the Health Care Workforce, will be conducted. Geropsychiatric nursing is the master’s level subspecialty within the adult-psychiatric mental health nursing field. Few educational programs focus on this specialty, and, unfortunately, few professional curricula include adequate content on mental health and aging. 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). 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/). The geropsychiatric nursing Collaborative has produced a vidoe on the role of geropsychiatric nursing in the mental health of elder people (www.aannet.org/i4a/pages/index.cfm?pageid=4501). Kolanowski and Piven (2006) provide a comprehensive literature review of research in geropsychiatric nursing and recommendations for future directions. Increased attention to preparation of mental health professionals, as well as continued research on mental health in aging, are important initiatives to improve care delivery for the growing numbers of older adults. 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 cormorbid mood-anxiety disorders suggest the importance of further investigation of the modifying influence of anxiety on depression treatment outcomes (Byers et al., 2010). 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). Byers and colleagues (2010) conducted a large-scale study of mood and anxiety disorders among older adults and reported that while prevalence rates of DSM-IV mood and anxiety disorders in late life tend to decline with age, the rates of anxiety disorders are as high or even higher than mood disorders. Among community-dwelling older adults aged 70 to 79, this study found an overall rate of anxiety of 19% (20% in women and 12% in men). Phobic disorders were the most prevalent individual disorder. Phobias, especially those associated with falling, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD), are increasingly emerging for the first time in late life. Women have higher prevalence rates of symptoms of anxiety and coexisting depression-anxiety than men. These authors noted that anxiety disorders were prominent and pervasive in older adults even onto the oldest years (85 and over). Anxiety symptoms and disorders are significant yet understudied conditions in older adults. Anxiety in older people is not often thought of as a serious problem, and there is little research or empirical data on anxiety in older people. Similar to other mental health problems, the diagnostic criteria and treatment methods for anxiety disorders are largely based on data from young and middle-aged adults and may not reflect the unique problems of older adults (Smith, 2005; Wetherell et al., 2005). 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) (Chapter 19). 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 co-morbid 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. 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, 2010). 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. Whether symptoms represent a diagnosable anxiety disorder is perhaps less important than the fact that the individual will suffer needlessly if assessment and treatment are not addressed. 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 (Chapter 19). When co-morbid 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. Few assessment instruments are designed and evaluated for older adults, and if such instruments are used, they should be weighed carefully with other data—complaints, physical exam, history, and collateral interview data (Smith, 2005). Box 18-6 presents suggested questions to identify anxiety disorders in older people. 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, co-morbid medical conditions, and any current medication regimen. Nonpharmacological interventions are preferred and are often used in conjunction with medication (Smith, 2005). Cognitive behavioral therapy (CBT) and relaxation training are effective psychosocial treatments for older adults with anxiety disorders or symptoms (Thorp et al., 2009). 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. Significant decreases in anxiety and depression over time have been reported when older women participated in a course using psychoeducation and skills training (Smith, 2005). Interventions for stress management discussed earlier including meditation, yoga, and other therapies are also important in the treatment and management of anxiety in older people. Suggested interventions for anxiety in older adults are presented in Box 18-7. 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. Over the long term, individuals with PTSD may be impaired in work, may have maladaptive lifestyles, and do not develop close relationships. Avoidance or numbing, dissociation, intrusive symptoms, and survivor guilt seem to occur less frequently in older people as symptoms of PTSD, whereas estrangement from others may occur more often (Wetherell et al., 2005). 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 long-lived 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. 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 18-8 provides some clinical examples of PTSD. 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 past history and life experiences is essential in understanding behavior and implementing appropriate interventions. An instrument to assess PTSD in older adults can be found at http://consultgerirn.org/uploads/File/trythis/try_this_19.pdf (Box 18-9). BOX 18-9 Assessment of PTSD: http://consultgerirn.org/uploads/File/trythis/try_this_19.pdf Assessment of depression: http://consultgerirn.org/topics/depression/want_to_know_more Assessment of suicidal risk: http://consultgerirn.org/topics/depression/need_help_stat/ Assessment of alcohol use: http://consultgerirn.org/uploads/File/trythis/try_this_17.pdf Detection of depression in older adults with dementia Evidence-Based Guideline: www.guideline.gov/summary.aspx?doc_id=11054&nbr=005833&string=depression+and+dementia Evans L: Mental health issues in aging: http:hartfordign.org/uploads/File/gnec_state_of_science_papers/gnec_mental_health.pdf
Mental Health
http://evolve.elsevier.com/Ebersole/TwdHlthAging
Stress and Coping In Late Life
Stress and Stressors
Effects of Stress
Factors Affecting Stress
Hardiness
Resilience
Resourcefulness
Coping
Coping Strategies
Promoting Healthy Aging: Implications for Gerontological Nursing
Assessment
Factors Influencing Mental Health Care
Attitudes and Beliefs
Availability and Adequacy of Mental Health Care
Settings of Care
Cultural and Ethnic Disparities
Geropsychiatric Nursing
Mental Health Disorders
Anxiety Disorders
Prevalence
Promoting Healthy Aging: Implications for Gerontological Nursing
Assessment
Interventions
Nonpharmacological
Other Anxiety Disorders
Posttraumatic Stress Disorder
Assessment and Intervention
EVIDENCE-BASED Protocols for Mental Health Disorders in Older Adults
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