Effect of Ageism on Diagnosis and Treatment

Older individuals usually seek care from their primary care physician for a physical problem, even though the underlying cause could be a mental or emotional problem. When the older person visits a primary care physician in family practice or internal medicine, the physician may not see that the real cause is mental or emotional because he or she may lack specialized education or experience in the needs of older clients. The physician may not order the appropriate number and type of diagnostic tests needed to make an accurate diagnosis because of the additional expense or a false belief that the observed behavior is “part of the normal aging process” or that mental health treatment is “not effective in older clients.” These are examples of ageism, a negative, prejudiced view of aging and older persons (see Chapter 1). In addition, the physician may note vague symptoms of a cognitive disorder and give the client an outdated diagnosis such as senile dementia, or a meaningless diagnosis such as organic brain syndrome, without the benefit of specific diagnosis or treatment.

Prescription medications may be ordered for anxiety or depression without determining the cause. Medications may be ordered for aggressive, disruptive, paranoid-type behavior without assessing the reasons for the behavior. Thus symptoms may be suppressed without determining the cause and possible cure. This type of action is similar to giving medication for pain without knowing what causes the pain, which may result in severe complications later, such as a ruptured appendix or gallbladder.

Preventing Premature Institutionalization

Adequate, accurate diagnosis is essential. Some conditions (e.g., Alzheimer’s disease) have no specific cure, but it is essential to know whether the symptoms and behavior are reversible. Even those irreversible disorders can and should be treated with appropriate medications, if useful, and with effective communication techniques and environmental strategies as needed.

Approximately 5% of people in this country live in extended care facilities, and the lifetime risk of admission to an extended care facility in the United States is 25% to 50%. By 2040 as many as 4 million Americans will live in long-term care settings. The incidence of dementia and other psychiatric disorders in this growing population will range from 51% to 94% (Zisook, 2008). The changing demographics of our society and the anticipated growth of the elderly population during the next few decades have created a need for nurse practitioners and other health care providers to develop age-related interventions that address the mental health needs of an aging population.

Prevention of Mental Illness

The focus on prevention of physical illnesses among older adults has increased in recent years. However, there has been less focus on the prevention of mental illness, especially among older adults. As previously mentioned, part of this problem may be a result of ageism. Another reason may be the lack of specific, well-considered, planned programs and activities for older persons, the primary focus of which is the prevention of mental and emotional problems.

Retirement planning seminars and workshops have been provided by some employers for many years. However, these sessions often focus on financial planning; some time is also usually spent on living arrangements, physical health, and leisure activities. Perhaps it can be concluded that all these factors are related to mental health wellness. However, specific discussion of mental health wellness, issues, and prevention of mental disorders during retirement is not usually stressed. With the many losses that may accompany retirement, such as the loss of challenging and stimulating work, the loss of relationships with colleagues, and the reduction of income, these issues should be considered and plans should be made.

Physical Wellness

Physical wellness is obviously important to mental health wellness. The young-old, those ages 65 to 74, are increasingly interested in health promotion activities such as good nutrition, mild aerobic exercise, and routine health assessments by a qualified health care professional. They attend health education classes at wellness centers, senior centers, American Association of Retired Persons (AARP) chapter meetings, and church meetings, where they learn about good health practices and the dangers of polypharmacy, thus contributing to their mental health wellness. They learn that continued physical and mental activities are essential to good health.

Activities that contribute to mental health wellness may be volunteer activities based on experience and expertise; part-time employment; continuing education to seek a degree (an increasing number of people in their 70s and 80s are completing baccalaureate, master’s, and doctoral degrees); attendance at local or regional workshops or seminars; and participation in political organizations, activities, and hostel programs on university campuses.

Older adults who experience acute physical illnesses and recover quickly are probably not as at risk for mental illnesses or disorders as those who develop chronic, long-lasting, incurable diseases that cause them to become frustrated, depressed, and sometimes suicidal.

Support Systems

Another factor essential in maintaining mental health wellness in old age is a strong support system. Support may be provided by family members, the church, friends, neighbors, and others. A person needs someone to turn to, confide in, and have available during times of wellness and illness. This type of support is especially important when people reach the older ages, especially the late 80s, 90s, and 100s, because they are more likely to develop physical and dependency needs.

The family continues to be the first source of support for older adults. This support may be regular contact through visiting or telephoning; participation in recreational activities with them; social and psychologic support; assistance with transportation, shopping, and financial matters such as paying bills; or direct physical caregiving.

The church is the second source of support for many older adults. For some it may be the first place they turn. They may have lost their spouses, siblings, and adult children to death, or, in today’s mobile society, adult children may live thousands of miles away and not be readily available in times of need.

Social contact is an essential human element that has direct effects on health and emotional well-being. Relationships also act as potential buffers against stress (Horwitz & Wakefield, 2009; Snyder, 2008). Both informal and formal fulfilling human connections can be healthful. Formal supports may include a member of the clergy, housekeeper, visiting nurse, or psychotherapist. Informal relations are family members and casual contacts, perhaps the grocery store clerk. For some elderly persons, close neighbors are a crucial source of informal support. Studies indicate that pets are a source of relational support. Elderly pet owners have been shown to be less depressed, better able to tolerate social isolation, and more active than those without pets (Touhy & Jett, 2010).

Role of the Nurse in Mental Health Wellness

Nurses need to be aware of their personal attitudes and opinions about aging and the care of older persons. Ageism is usually the result of inaccurate information and inadequate knowledge. The nurse who understands the aging process and the conditions that may accompany the aging process does not label an acutely ill hospitalized older adult as demented when the client’s behavior is most likely a symptom of delirium, a reversible, temporary condition brought on by a change in environment, anesthesia, medication, or another physical factor, such as pain (see Chapter 15) or infection (see Chapter 16). The nurse should communicate with and attentively listen to the older person, taking into consideration any sensory deficits identified during the admission history and physical examination. The nurse should involve the older client and his or her family in the care plan. The nurse should do everything possible to maintain or to enhance the older client’s feelings of self-worth by providing privacy, seeking his or her opinion in matters of care, treating the older client with respect, and, if needed, seeking referrals for specific diagnoses and treatment of possible mental illnesses or disorders.

A nurse often functions as a coordinator of the care provided to older adult clients. As a coordinator attempting to provide a holistic approach, the nurse assesses the client’s mental health needs and provides intervention based on the assessment. Older adult clients benefit from nurses who have a comprehensive knowledge of the community’s mental health resources. The ability to anticipate client needs and respond in a proactive manner to mental health issues by referral to a community resource (e.g., a support group) can significantly enhance a nurse’s effectiveness.

Nurses with specialty training and experience in geropsychiatric issues may take an expanded role in the provision of services designed to enhance mental health wellness in the older adult population. For example, a specialty nurse could meet with individuals preparing to retire to discuss emotional experiences common to new retirees. Another nurse might moderate a support group for older adults who have recently moved to the homes of adult children. By acknowledging their shared issue of decreased independence, the older persons can explore available coping skills and improve their adjustment techniques.

Depression

Minor depression affects up to 50% of residents in long-term care facilities and up to 25% in primary care settings and is associated with considerable discomfort, disability, and risk of morbidity, as well as excessive use of non–mental health services. Bipolar affective disorder is fairly common in elderly persons, with a prevalence of 0.1% to 0.43% in the United States. However, between 10% and 20% of geriatric patients have bipolar disorder, as do 5% of those admitted to geropsychiatric inpatient units. Major depression with psychotic features occurs in 15% of community sample populations. Among geriatric inpatients, the rate may reach 45%. Unfortunately, the appropriate diagnosis of psychotic depression is missed in about 30% of emergency department admissions (Lavretsky, 2008). Unfortunately depression in older adults is often overlooked and therefore left untreated. When left untreated, depression can lead to an increase in both morbidity and mortality among older adults. Equally problematic is the fact that depressive disorders are often misdiagnosed as a result of the unique symptoms manifested by depressed older adults. Symptoms that may appear to be representative of a cognitive disorder are often really symptoms of depression (Box 14–2 and Nursing Care Plan).

A number of theories attempt to explain the cause of depression. Each theory presents a different viewpoint or causative factor, but the depression that clinicians see in older adults seems to represent an interplay of biologic, psychologic, and social factors (Lovinger, 2007). Older adults at the highest risk for depressive symptoms are women older than age 85 who are unmarried, living in an urban area, living in a long-term care setting, experiencing physical illness or disability, lacking adequate social support, of a low socioeconomic status, or experiencing a significant loss; a combination of these factors may also exist. Factors that seem to protect older adults from depression include hardiness (defined as a personal characteristic of commitment, control, and capability to handle challenges) and the development of healthy attitudes toward death.

Depression in older adults may be divided into the two broad categories of depressive disorder and bipolar disorder. Depressive disorders can range from an acute major depression to dysthymia, which is a chronic (2 years or more) range of depressive symptoms. In bipolar disorders the depressive symptoms alternate with manic symptoms, which are seen as an abnormal elevation of mood. The swings between depression and mania can be drastic, as seen in bipolar I disorder; can alternate between major depression and less severe manic behavior (hypomania), as seen in bipolar II disorder; or may alternate between signs of dysthymia and other hypomanic symptoms; these latter clients are referred to as cyclothymic (APA, 2000).

Although the course of depressive symptoms varies from individual to individual, some common elements can be found in the development of depression in older adults. A change in self-concept, combined with a sense of loneliness and isolation, often leads to a feeling of increased dependence on family members or other caregivers. This sense of dependency can lead to a progressive decline as the depression begins. Also contributing to the development of depression are factors such as preexisting mental illness and the loss of loved ones, especially if multiple losses occur in a short period. A number of physical disorders are associated with the development of depression in older adults. These include congestive heart failure, diabetes mellitus, infectious diseases, changes in gastrointestinal function, cancer, seizure disorders, anemia, and sleep disorders. A number of medications used by older adults are associated with depressive symptoms; in particular, cardiovascular agents, antianxiety drugs, amphetamines, narcotics, and hormone medications may all play a role in the development of depression. Substance abuse of alcohol, illegal drugs, prescription medications, or over-the-counter medications can pose a significant risk for depression (Kirn, 2006) (Box 14–3).

Symptoms of depression in older adults can include distressful feelings, cognitive changes, behavioral changes, and physical symptoms. Feelings that older adults may experience when they are depressed include malaise, fatigue, lack of interest, inability to experience pleasure, a sense of uselessness, hopelessness, helplessness, decreased sexual interest, increased dependency, and anxiety. Cognitive changes include a slowing or unreliability of memory, paranoia, and agitation, a focus on the past, thoughts of death, and thoughts of suicide. Older adults with depression may show behavioral changes such as difficulty completing activities of daily living (ADLs), change in appetite (most commonly, a decrease), changes in sleeping patterns (usually insomnia), lowered energy level, poor grooming, and withdrawal from people and interests they have enjoyed in the past. Physical symptoms commonly seen in older adults experiencing depression include muscle aches, abdominal pain or tightness, flatulence, nausea and vomiting, dry mouth, and headaches (Kirn, 2007; Kyomen & Whitfield, 2008).

Diagnosis

After a comprehensive assessment of depression has been completed, nursing diagnoses may be used to delineate identified human responses. The following is a list of sample nursing diagnoses commonly identified in older adults experiencing depression, with examples of possible causes:

Planning and Expected Outcomes

In planning care for older adults with depression, the nurse should set both short- and long-term goals appropriate for the nursing diagnoses identified for a given client. Expected outcomes for clients with depression include the following:

Intervention

Nurses have a unique role in the interdisciplinary team approach that is most often used in the treatment of depression. The focus of nursing care is to assist with the human responses that occur as a result of the depression. Nursing intervention can occur at numerous points along the continuum of care in settings ranging from clients’ homes to outpatient clinics to partial hospitalization programs or inpatient units.

Regardless of the setting in which nursing care is provided, safety is the primary goal. Depressed older adults are often at risk because of their inability to care for themselves; they may also be at risk as a result of self-destructive behavior or suicidal plans. Nurses must constantly assess the level of risk for clients with whom they work and must take appropriate steps to ensure their clients’ safety.

Physical needs are also a priority for frequent intervention in depressed older adults. They may be unable to perform their own ADLs and need assistance or motivation to do so. They may also have numerous somatic concerns such as insomnia, decreased appetite, pain, gastrointestinal distress, and headaches.

The nurse’s ability to positively effect change in older adults’ responses to depression lies in the development of therapeutic relationships. The nurse must show unconditional positive regard and empathy in a professional manner so that trust can be developed. Once trust has been established, clients become far more open to the nurse’s intervention.

In an inpatient setting a professional nurse is most often considered the milieu manager and, as such, must provide an optimum environment for client treatment. Nursing has considered the role that the environment plays in client recovery as far back as the experiences of Florence Nightingale. Environmental factors include color, light, art, movement, level of activity, and interpersonal environment.

A number of psychotherapeutic modalities are used to respond to depression in older adults. These include milieu, individual, family, and group therapy. Group therapy is particularly effective with older adults because it allows them to express and to receive support. A specific type of group therapy that seems to be useful with older adults is reminiscence therapy, in which they are encouraged to discuss past events to identify problem-solving skills that have worked for them in the past. Reminiscence groups involve a caring facilitator (who does not have to be a health care professional) who encourages and listens to group members share experiences from the past. The facilitator may initiate a topic of interest to the group, such as childhood and early school experiences, certain family holiday rituals, marriage and the time when their children were young, or popular movies and music from the past. Most reminiscing is about happy or pleasant events from the past. If sad, unhappy, or unresolved problems begin to emerge, the group facilitator should obtain the assistance of a trained mental health professional. Older adults who display unhealthy behavioral changes in response to their depression may also benefit from behavior therapy. The key to behavior therapy in older adults is to use a direct, structured approach that maintains the clients’ integrity and autonomy. Offering clients options with clearly delineated consequences for their choices enables them to maintain a sense of control. Some older people do not feel comfortable sharing emotions and feelings in a group, so individual therapy or medication may be the best choice.

Nurses also play a significant role in the biologic interventions that are used to treat depression. A thorough understanding of the appropriate use of psychotherapeutic medications, drug–drug interactions, drug–food interactions, potential adverse reactions, and legal and ethical implications of these medications is necessary for the nurse to intervene appropriately with depressed older adults. Electroconvulsive therapy (ECT) is sometimes used for depression in older adults. The nurse who intervenes with clients receiving ECT must have a comprehensive understanding of the indications, benefits, and risks inherent in this therapeutic intervention.

Nursing intervention for older adults who are depressed occurs on three levels: primary, secondary, and tertiary. Primary intervention involves actions that promote health and decrease the likelihood of depression. Secondary intervention includes the nurse’s response when clients are experiencing the acute symptoms of depression. Tertiary intervention is the restorative or rehabilitative functions that the nurse performs to assist clients in their recovery process. An important aspect of tertiary intervention involving clients with depression is teaching new coping skills to lessen the likelihood of recurring depression (see Client/Family Teaching box).

Evaluation

In evaluating the care provided to older adults experiencing depression, the nurse should initially compare client outcomes with the short- and long-term goals outlined in the planning phase of the nursing process and document client progress toward achievement of the goals. Appropriate alterations should then be made to the continuing treatment plan to ensure the optimum client response. It is helpful to assess the level of satisfaction that clients and their families feel with the nursing care that has been provided. It is also important for nurses to assess their own reactions to clients and the care that has been provided to ascertain the effect (positive or negative) that the clients have had on the nurse.

Suicide

The Elderly Suicide Fact Sheet (2008) from the American Association of Suicidology provides the following statistics. The elderly make up 12.4% of the population in 2004, and they accounted for almost 16.6% of all suicides. The rate of suicide for the elderly for 2005 was 14.7 per 100,000. There was one elderly suicide every 100 minutes. There were about 14.5 elderly suicides each day, resulting in 5404 suicides in among those 65 or older. Elderly white men were at the highest risk with a rate of approximately 33 suicides per 100,000 each year. White men older than the age of 85, the “old-old,” were at the greatest risk of all age–gender–race groups. In 2005, the suicide rate for these men was 45.23 per 100,000. That was 2.5 times the current rate for men of all ages (17.7 per 100,000). Of elderly suicides, 84.19% were male, and the rate of male suicides in late life was 5.2 times greater than that for female suicides. The rate of suicide for women typically declines after age 60 (after peaking in middle adulthood, ages 45 to 49).

The suicide rate for the elderly reached a peak in 1987 at 21.8 per 100,000 people. Since 1987, the rate of elderly suicides has declined 28% (down to 14.7 in 2005). This is the largest decline in suicide rates among the elderly since the 1930s.

Although older adults attempt suicide less often than those in other age groups, they have a higher completion rate. For all ages combined, there is an estimated one suicide for every 25 attempted suicides. Among the young (15 to 24 years) there is an estimated one suicide for every 100 to 200 attempts. For those older than the age of 65, there is one estimated suicide for every four attempted suicides.

In 2005, suicide rates ranged from 12.64 per 100,000 among persons aged 65 to 74, to 17.08 per 100,000 persons aged 75 to 84, to 16.94 per 100,000 persons aged 85 or older. Firearms were the most common means (72%) used for completing suicide among the elderly. Men (92%) used firearms 11.5 times more often than women (8%). Alcohol or substance abuse plays a diminishing role in later life suicides compared with younger suicides. One of the leading causes of suicide among the elderly is depression, often undiagnosed and or untreated. The act of completing suicide is rarely preceded by only one cause or one reason. In the elderly, common risk factors include

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