psychosocial needs of older adults

aging

chronological age is an indicator of function

limited regenerative abilities

increased susceptibility to disease

aging: mental health issues due to:

life stress events, retirement

loss (spouse, family/friends, pets, independence)

diminished senses

comorbid illnesses

polypharm, adverse drug reactions (ADRs)

hospitalization

higher risk of complications and death

late life mental illness in OA

less likely to be accurately diagnosed, receive treatment, and covered by medicare

depression, cognitive deficits, prolonged grieving common but not a normal part of aging

depression in OA

under identified

often confused with dementia, delirium

key differences: onset of mental status change/course, LOC, attention span

suicide risk and depression

accounts for 70% of late life suicides, esp in white non Hispanic men. 7x more in M than F

underreported

numbers do not reflect passive suicide: alcohol use disorder, starvation, overdosing/mixing meds, purposeful driving, losing will to live

ongoing effort to educate HC providers to recognize and treat

suicide risks and protective factors

demographics (age, gender, ethnicity)

diagnosable psychiatric illness

psychological well being/personality

biological status

stressful life events

access to weapons, large dose meds

chronic or terminal illness

protective: spirituality, having children, perception of family and social support

suicide assessment

dont:

assume not a problem in OA

ignore, rather explore: ask the right questions, typical day, other signs, document, refer to mental health team

depression treatment in OA

SSRIs: 1st line

SNRIs: if pain or diabetic neuropathy present

treatment resistant: psychostimulants (methylphenidate), ECT

multimodal treatment: meds and counseling

anxiety disorders

peak at different ages, prevalence estimates vary widely

hard to diagnose

most common: fear of falling; can be disabling

risk factors: low socioeconomic status, childlessness, past trauma

treatment: SSRIs & CBT

delirium

time-limited medical complication often due to metabolic changes (electrolyte imbalance, infection)

sudden onset of confusion

develops over short period of time (hours)

s/s: confusion/changes in cognition. fluctuations in consciousness

assess: confusion assessment method (CAM); consider baseline/comparison

treatment: ensure safety and identify cause

dementia

most common cause: alzheimer’s

s/s:

4 A’s: amnesia, aphasia, apraxia, agnosia

gradual change/increase in confusion (years)

changes in executive function:
-early: instrumental ADLs, judgement, insight
-later: dependent in all ADLs

pain

not a normal part of aging

very common; 85% conditions/predispose

affects ADLs, sense of well-beings, QOL

leads to stress, sleep & mobility problems, delayed healing, decreased appetite, agitation

self medicate with alcohol, pain meds → addiction

chronic pain linked to depression, isolation, loneliness, hopelessness

pain assessment instruments

pain assessment in advanced dementia (PAINAD): non verbal pts

Wong Baker FACES

mcgill pain questionnaire (MPQ): asks characteristics of pain

pain management

pharmacologic/non opioids: NSAIDs, acetaminophen, COX-2 inhibitors, ibuprofen, naproxen, tramadol

opioids: reserved use (cancer pain only)

neuropathy: SNRIs (avoid gabapentinoids; SE: sedation → falls)

alternative: hydrotherapy, TENS, acupuncture

AUD risk factors

losses, retirement, loneliness

loss of structure of daily life, purpose in life

past drinking history, support of peers in behavior

used for stress reduction, pain, depression

male, single, long term HS education, low income

smoking

history of depression, pain (self med)

alcohol use disorder (AUD)

difficult to identify: personality/behavior changes

should screen all OAs, esp if suspected. michigan alcholism screening test: geriatric version

treatment: alcohol screening & brief interventions, self help groups, CBT

AUD s/s

self neglect, malnutrition, weight loss

peripheral neuropathy, falls, unexplained bruises

diarrhea, urinary incontinence, loss of function status

depression; confusion/dementia

opioid use disorder (OUD)

two categories: lifelong use with survival to older age; use/entry via opioid prescription later in life

why so common?: pain as 5th VS driven by big pharma, using pain scores rather than assessing function, over prescription and availability

beers criteria: avoid muscle relaxants, tramadol, tricyclics, gabapentinoids, no opioids if history of falls or fracture

treatment: opioid detox with buprenorphine

psychosocial contributors to assess in OAs with OUD

stigma/shame: “addict” label

bereavement/grief issues, low self esteem

social isolation/loneliness

family conflict, estrangement

problems managing time, boredom

HC concerns of OA

financial burden: HC expenses 4x higher; most on fixed income, difficult choices; coverage gap

medicare part D (supplemental) plans help with some expenses/prescription drugs after deductible

nurse as educator/pt advocate: resources like AARP, area agency on aging

caregiver burden

physical, emotional, financial and psychosocial support provided to a loved one with chronic illness; often spouse, children

sandwich generation: parents who take care of their children as well as their parents

physical/functional disability challenging as is dementia and chronic mental illness

nurse as educator/advocate: resource such as respite care options offer caregivers a break

ageism

defined: bias against older people based on advanced age; stigma persists

growing older not viewed as privileged or revered social status/wisdom

advance directives

types, must be in writing: living will, durable medical POA, directive to physician (surrogate D-M), legal guardianship (court-ordered)

psychiatric advance directive: those with serious mental illness designate a HC agent to make treatment decisions during relapse

nsg care of OA

must first recognize any ageist views in self: many myths, develop positive attitude, esp stigma of mental illness, respect autonomy

knowledge of aging process, chronic illness, geriatric syndromes, mental health issues

assessment strategies recommendations

comprehensive geriatric assessment; mental status exam

establish rapport, conduct interview in private area, adequate lighting, low noise

systematic review of current meds: prescribed, OTC, herbals

polypharmacy

esp prevalent in OAs/chronic conditions

risk of adverse drug reactions doubles if taking 5-7 meds

prescribing cascade: when drug induced s/s treated with another drug

beers criteria: decrease in functional status, increase falls, urinary incontinence, confusion, malnutrition

driving and OAs

problematic for numerous reasons:
sensory: vision loss (esp at night), hearing decreases, reaction time, decrease mobility, cognitive changes

major safety concern:
signifies loss of independence
a must if alzheimer’s/dementia present
driving evaluation to determine capacity
must be done gently
best to have provider suggest (vs family)

older adult abuse

est 5 million older Americans are abused every year

should explore during nsg assessment

includes: physical abuse, neglect (not being fed, cared for), financial exploitation often by family, friends, phone scams, AI use, difficult to ascertain (embarrassed/ashamed)

general intervention strategies

ensure glasses on

hearing aid working/use amplifier

empathy, active listening, allow time/response

encouraging ventilation of feelings, normalizing emotional response, reminiscence

reestablishing emotional equilibrium if anxious

providing health education, alternative: large print, white spaces, sans serif font

assist with problem solving approaches

treatment settings

inpatient mental health care if severe psychiatric conditions and/or risk of harm to self/others

hospitalization: opportunity for physical workup, teaching about meds, promoting self care

alternative care settings

skilled nsg facilities, long term care

assisted living

independent living: retirement community with staff available

respite care

day care programs

health home care

community based programs

most are not covered by Medicare/other insurance

goal: maintain in community; “age in place”

dual sensory loss

problems with both vision and hearing can substantially impact function, increase feelings of isolation and increases risk for dementia