SPECIAL PROBLEMS OF THE ELDERLY
BIOPSYCHOSOCIAL ADJUSTMENTS AND PSYCHIATRIC ILLNESSES
The elderly segment of our population is currently growing at a faster rate than any other age group. Census projections are that by 2000 there will be almost 35 million people in our country over 65 years of age. This large group can be subdivided into older citizens (71-80), the “old-old” (81-90) and the “very old-old” (91-100). Currently, the greatest amount of depression, organic mental disorders and chronic disabling illnesses occurs in the 81-90 year olds. But before we explore these issues let’s review some of the usual and typical challenges of aging.
Because of the post WWII baby boom, our country is experiencing a huge block of adults who will approach old age simultaneously and with ore social awareness, political power and expectations of the health care system than ever before. Traditionally, several impediments including ageism, myths about the aging process, stigma and access issues have disabled the elderly in their pursuit of services. These blocks stand to be severely challenged by the baby boomer block.
Ageism refers to negative and hostile attitudes toward the elderly who are viewed with disrespect or as a burden on society as a whole. Subtle ageism may be experienced in caring or interacting with the elderly and impair the quality of services provided to aging adults. Some views which reflect age bias include:
- Beliefs that the elderly are too rigid or unable to change and therefore rationalizing that certain services or interventions are a waste of time.
- An attitude of “why bother” because the elderly are going to die anyway.
- Avoidance of the elderly because of personal fears of aging or unresolved conflicts in our relationships with parents or other older significant others. Such views may impair or even prevent health care providers from objective assessment and intervention.
Our culture has supported a variety of myths about aging which are negative and unfounded. Loneliness, depression or senility are not aspects of “normal” aging, for example. Many elderly have internalized such myths and may not seek treatment for eminently treatable problems such as depression. Care providers must assess their own buy-in to such negative stereotypes and participate in debunking such myths.
As the current generation ages we can expect the stigma associated with mental illness to diminish. However, the current older generation still subscribes to many fears or shameful feelings regarding mental illness. In their youth, psychiatric problems were less understood treatment was both less effective and less available, and families tended to ignore or hide psychiatric problems. Care givers much examine their own attitudes as well as make consistent efforts to destigmatize mental illness for the elderly.
Access to service is a problem that exists on several levels. Financial problems are often a deterrent for the elderly in accessing needed services. In our current economy, services are being cut back routinely, and the remaining services become accessible to less and less clients. Physical barriers such as inaccessible buildings and rest rooms may limit access to some elderly from connecting with needed services. Disabling illness which diminish mobility also limit access ad the limited availability of home-care, long-term care, attendant care, etc, present access problems to some segments of the elderly. Care providers must advocate for the needs of our older citizens.
In addition to social, political and cultural issues pertinent to the elderly, the later years have their own set of specific biopsychosocial factors which present challenges to aging adults. Biological aging is expected and to varying degrees to accepted part of growing old. Yet individuals of the same chronological age may, in fact, age quite differently. Many factors impact biological aging such as stress experienced in life and coping skills, heredity, nutrition, exercise, cultural influences, presence or absence of illness and relationships.
There are a number of theorists who have focused on the aging process. Among them seems to be some consensus that an adequate adjustment to older age includes finding meaning in the pursuits of older adulthood, an ability to review one’s life and reminisce positively about life events and an ability to integrate the past into the present achieving some sense of accomplishment and wholeness. These abilities will allow the older adult a sense of satisfaction and assist them in coping with the changes and challenges of the later years.
One of the hallmarks of the aging process is a generalized slowing of thought processes and motor activities. Although this slowing is certainly individualized, it is universal. With aging comes some sensory losses – vision, hearing, smell, etc. become less acute causing input to less sharply defined and processed. This does not mean, however, that intelligence diminishes. Researchers do not agree on the supposed decline in intelligence associated with aging and many suspect reported declines have more to do with artifacts of testing older adults. Some studies even report an increase in IQ in older adults.
Memory deficits have long been associated with aging. In fact, people may begin identifying memory impairment in early or mid-adulthood and presume they are on a down hill slide. A variety of factors influence memory such as attention span, fatigue, boredom and rate of input to name a few. Such factors can be adjusted to facilitate enhanced memory. The memory process involves three steps:
- Receiving the information
- Storing the information
- Retrieving the information
Impairment can be related to problems at any stage of this process. Inputting too much information at once can interfere with reception. This is often the problem when young adults who juggle careers, family, and households note memory problems. Storage of information can be enhanced when information is meaningful and relevant. Retrieval of information can be facilitated by use of mediators – associations or gimmicks such as acronyms. Also memory can be boosted by pacing oneself and, or course, repetition.
Undeniably the older years have a certain set of stressors associated with them – retirement, losses of loved ones, physical health problems, and limited financial resources are serious challenges. Coping skills learned over the life style are not lost in later years, however, and acquiring new coping skills is quite realistic. Many older adults cope and adjust to the psychobiological challenges of later years quite well. Among those who do not fare as well depression is the most prevalent psychiatric disorder of these years. Fortunately it is also the most treatable.
When depression occurs in the elderly, symptoms are similar to those experienced in depression occurring at earlier points in the life cycle. Some misleading symptoms may characterize depression in the later years including memory loss, disorientation and agitation. These symptoms can cause clinicians to misdiagnose depression as an organic, irreversible impairment. Additionally, older adults often romanticize their depression. Distressing emotional responses may be embarrassing and frightening to older adults who may exaggerate the stigma associated with mental illness. The depressed elderly may unconsciously focus on physical complaints as a way of expressing their distress. Chronic complaints of G.I. distress, constipation, headaches, dyspnea, chest or musculoskeletal pain which do not respond to treatment or seem to have no basis may, in fact, represent a clinical depression. This is important to be mindful of since depressed older adults have a higher rate of suicide attempts than any other age group and a higher lethality rate, too.
Other psychiatric disorders which present with some frequency in older adults include other mood disorders, adjustment disorders and substance abuse. Chemical dependency can and does develop in later life. Chronic pain, inadequate coping mechanisms, losses of significant others and support systems, inadequate adjustments to changes in life style and identity, increased use of prescription and over-the-counter medications are a few of the factors that may predispose older adults to develop chemical dependency.
PSYCHOPHARMACOLOGY
Effective psychopharmalogical intervention with older adults is difficult to achieve. Some reasons for this include aspects of normal aging. As one grows older, kidney function diminishes due to neuron loss, liver function diminishes and lung function diminishes. These changes cause drugs to be detoxified at a slower rate and the half-life of drugs to be longer. Another complicating factor is that many older adults are on various prescription medicines. The average older patient takes 12 medications daily. Prescriptions may be written by several different physicians. Pill sharing commonly occurs among groups of friends, as well. All these factors create a very complicated baseline on to which psychopharmacologic agents may be added.
Many prescribing clinicians are well aware of the hypersensitivity older adults may experience to anti-depressant drugs, anxielytic agents and anti-psychotic medications, Low doses are the rule with slow incremental dosage increases. Careful monitoring for therapeutic effectiveness is essential to arrive at the correct, therapeutic dosage.
When low-dose psychopharmacology is initiated, the prescribing clinician must carefully review all the other drugs the patient takes. This is necessary to evaluate for potential complications including complications from side effects. Many psychotherapeutic agents have considerable side effects or may increase the side effect potential of drugs the patient was on previously. Older adults use significant amounts of over-the-counter medications particularly sleep aides and laxatives. Careful patient teaching is essential to avoid side effects such as drowsiness or lethargy which could be enhanced by over-the-counter drugs as well as other prescriptive agents.. Patient teaching should be concise, meaningful and repeated.
DELIRIUM AND DEMENTIA
Delirium and dementia are not problems exclusively found in older adults but these two conditions are associated with the later years when they may occur more often.These are two distinct processes which may overlap in some individuals. This picture is further complicated by inaccurate use of the terminology. Both these conditions produce some confusion – a term which is often used if it were a separate condition.
To begin this discussion here are some definitions of major terms:
Delirium a physically based disorder which is characterized by rapid onset without a history of cognitive problems. Although delirium is typically of a short duration, it is a difficult and challenging condition. It is characterized by intermittent memory loss, confusion, disturbed sleep patterns and appetite, difficult maintaining or shifting attention, fluctuating levels of consciousness and incoherent or disordered speech. Underlying organic causes are usually found for an episode of delirium. Such causes may include drug toxicity, head trauma, a systemic infection, alcohol withdrawal, hypoxia, fluid and electrolyte imbalance or TIA’s. Delirium often worsens at night as in sundowner syndrome, This may be related to the hearing or vision impairments of the older years beginning exaggerated a low-light environment. Delirium is 99% reversible.
Dementia dementia is a progressive, primary degenerative condition. Its onset is insidious evidenced by a slow, steady decline. Alzheimer’s’ disease is the most common dementia. In the early stages of dementia, individuals are often aware of their decline, This awareness can trigger a clinical depression. Gradually, the demented adult looses perception of language, situations, identities, etc. Dementia is not normal aging. In addition to Alzheimer’s disease, dementia may be caused by metabolic disorders, Huntington Chorea, multi-infarct dementia, Binsewangers disease, carbon monoxide poisoning, cardiac arrest, head injuries, various infections, space occupying lesions, auto-immune disorders, alcoholism and some cases of epilepsy. Although the dementia associated with psychiatric disorders, drug toxicity, nutritional disorders and some metabolic disorders are treatable and may improve most dementias have a poor prognosis.
Depression a separate clinical entity can compound either of these disorders and complicate the clinical pictures. Remember that depression is very amenable to appropriate treatment.
Confusion too, may compound these disorders. Confusion can be caused by organic, sensory or emotionally based problems and has a good prognosis. In assessing for delirium and dementia, be a keen observer. The patient’s appearance and presentation may offer you some excellent clues. Observe and assess for:
Grooming a change in grooming or performance of ADL’s (not related to disability), may suggest a sudden onset of behavioral change as seen in delirium.
Affect and activity Level stable or fluctuating moods, agitated or hypoactive lability of affect is consistent with delirium while a flat, withdrawn mood may suggest depression.
Orientation check to see if the person is oriented to person, time, place and situation. Anxiety can impair memory so you may wish to repeat these questions later in the interview after you re-orient the patience once. Demented individuals may provide non-sensical replies if they are disoriented or their orientation may fluctuate.
Memory Assess both recent and remote memory. Demented individuals may respond irritably, or perseverate, or confabulate when questioned. Depressed persons may have difficulty concentrating and may not respond.
Identification Ask your patient to identify a couple of common articles such as your pen or watch. In dementia, agnosia (the inability to identify familiar objects) is often present.
Explore the patient’s medical history searching for physical problems which could affect cognitive functioning. Explore social history for recent losses or other stressors, explore alcohol and drug use patterns for clues regarding drug toxicity or alcoholism; explore prescription and over-the-counter drug use for toxicity issues or side effects, Always interview family members or friends who are present regarding medical history, patient’s self-care abilities, recent stressors, onset of cognitive changes, and family history of psychiatric disorders, alcoholism and dementia. Be sure to explore with both the patient and their significant others the onset and course of the symptoms.
There are proven interventions for working with older adults who suffer from confusion secondary to delirium or dementia. First, it is important the sudden or slow changes in cognition be noted and attended to. Ascertaining the underlying cause is essential and many underlying causes are highly responsive to appropriate treatment.
Secondly, pay attention to the physical aspects of the patient’s situation. Does the patient need pain relief? Pain can cause confusion. Remember that as we age, we need 3 X more light – this includes increased nighttime lighting to diminish misperceptions of unfamiliar surroundings. Background noise can add to confusion by distracting a person from focusing on the care giver attempting to communicate or by obscuring a direct communication. Another face of aging is that the urinary bladder shrinks requiring more frequent urination. Nocturia is normal in the elderly but nighttime wake-ups in strange rooms in a bed with side rails can be quite confusing and frightening, In regard to nighttime problems, also be aware the older adults require less sleep than young and middle aged folks., Many seniors do fine with five hours sleep. Use of sleeping pills to lengthen sleep that is adequate and age appropriate, is asking for problems. Schedules need to be adjusted to meet the needs of our patients not vice versa.
Attention to the familiar in the environment can significantly cut down on problems with confusion. Allowing patients to use their own clothes, a blanket from home or other personal objects can assist them to be more in touch with reality. Use family to be with patients during difficult times as much as possible.
Physical activity can be helpful, too. If your patient has a sitter, prepare a care plan which focuses on keeping the patient as active as possible. Motion can decrease agitation – if you have a rocking chair handy try it for an agitated older adult, Find simple chores for the patient – one gerontologist suggests allowing a patient to fold and refold the units washcloths. Such an activity can decrease tension, smoothes through repetition and provide an opportunity to do a familiar task.
When interacting with confused older adults use short simple sentences, Be patient – cognitive impairment significantly slows information reception and processing, Responses will take about three times as long, too. Minimize any decision making during periods of confusion., Another communication strategy is to focus your verbal interaction on calming and reassuring the individual. Clarifications of reality can be offered but do not argue or insist with a confused patient. This can provoke agitation. When circumstances in the environment are agitating, use the patient’s deficits to their advantage. Try and distract them from the present by engaging them in a conversation about their past life.
A final reminder about restraints – they almost uniformly increase confusion. Although patient safety is undeniably a major priority, alternatives to restraints such as use of a geri-chair are important solutions to these problems.
In our concurrent health-care environment, many acute care facilities include a skilled nursing facility or an extended care unit as part of the physical plant. If this is the case in your practice setting, utilize this resource for assistance in planning care and interventions when caring for confused elder adults. Phoning a colleague for suggestions and avoid “reinventing the wheel”. Also many SNF’s have a geriatric clinical nurse specialists who may be willing to consult to your service.
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