ch6 tb aging

An individual’s mental health is determined by many psychological, biological, and social factors such as

an unhealthy lifestyle, rapid social change, and poverty are associated with poor mental health. Stressful work conditions, social exclusion, risks of violence, ill physical health, and human rights violations also are associated with poor mental health

A major focus for the ICD is

on ease of use by clinicians and a reduction in the number of diagnoses. Of interest and in stark contrast to the DSM-5, this latest edition has removed the various personality disorders and now only has one diagnosis for personality disorder which is now determined by degree; mild, moderate, or severe.

Three criteria that mental health professionals consider when determining if an individual has a mental illness

first - How different is the behaviour from what is considered socially acceptable? Second - How disruptive is the behaviour? Does it significantly interfere with a person’s ability to function on a day-to-day basis? Third - To what degree is the person distressed by the behaviour?

A multidimensional approach to assessment has the most benefit for diagnosis. A good assessment involves

gathering data from several sources such as family members and healthcare professionals. Conducting a thorough assessment is important for several reasons. It is very difficult to provide appropriate care or develop an accurate treatment plan without accurate assessment.

The Beck Depression Inventory-II is a measure commonly used to screen for depressive symptoms in younger and middle-age adults. However, this measure of depressive symptoms includes questions about

fatigue, loss of interest in sex, and sleeping patterns. As a result, it is not the best measure to use with older adults as these symptoms can be the result of normal aging.

When using a screen to assess depressive symptoms in an older adult, the

Geriatric Depression Scale (GDS) should be used, as the types of questions noted above are not included in the GDS. As a result, artificially inflated scores in older adults are less likely when using the GDS.

Performance-based assessment

is an important method of assessment, in that it allows the clinician to observe how a person functions in their own environment

Instrumental Activities of Daily Living (IADLs)

can a person safely prepare meals? Are they aware of safety issues? Can they pay bills?

Activities of Daily Living (ADLs)

also are assessed including activities such as brushing one’s teeth, washing one’s face, or toileting independently.

An example of a negative bias is not assessing an older adult’s

sexual behaviours because of the belief that older adults are asexual.

A positive bias that can lead to inaccurate assessment is assuming that “little old ladies” are

sweet and kind and never become violent.

The second factor that can influence the assessment process is the environment that the assessment occurs in. For example

older adults often have an age-associated hearing loss. If the assessment takes place in a room with a lot of background noise, the individual may answer questions in such a way that may lead the healthcare professional to believe that the individual is confused when, in fact, all that person has is a hearing impairment. Other issues that can significantly interfere with an accurate psychological assessment in older adults are not considering such factors as English as a second language or not having appropriate norms to compare the cognitive performance of the individual being assessed.

When assessing people of any age, it is important for the healthcare professional to get

an individual’s best performance. However, medical appointments and investigations, psychological assessments, and other types of work-up can be very stressful for individuals of any age. This stress will certainly interfere with getting the individual’s best performance. In order to reduce the stress that older adults might experience during an assessment, Canadian researcher Sonia Lupien and her colleagues (2012) developed the Guidelines for Health Professionals and Scientists Working with Older Adults.

Beck argued that the main features of depression are negative thoughts about oneself, the world, and the future. He coined this

the “negative triad.”

The change in symptoms of depression over time, "including predictors of the development of depression in comparing health sectors, the Long-term Care sector demonstrated

the highest rates of symptoms of depression compared to the Home Care and Palliative Care sectors at both the baseline and the follow-up points of measurement. Statistically significant risk factors across all three sectors included reporting unmanaged pain and the expression of symptoms of depression at baseline while social connectedness emerged as a protective factor for depression across all three sectors. These researchers argue that these results suggest that more preventative and proactive work should be performed upon admission to the Long-term Care sector sector to avert late-life depression from occurring or worsening."

In LTC, residents complained about

superficial social connections in these settings. For example, recreational programming typically offers activities that focus on entertainment and distraction. Residents wanted more purposeful activities that provide opportunities for meaningful contributions or connections.

Theurer and her colleagues developed a peer mentoring program called Java Mentorship

It involves weekly meetings between resident mentors and community volunteer mentors, facilitated by a recreation therapist or volunteer coordinator. The program includes educational modules on effective mentoring, engaging less communicative mentees, and supporting those who are grieving, with the goal of reducing loneliness and depression among residents

Researchers have argued that lower rates of depression can be accounted for by

selective attrition in which those individuals who have depression earlier in life are less likely to live to old age because of suicide, and/or alcohol and drug abuse

Another explanation is that older adults may experience depression differently than do young- and middle-age adults. For example, older adults are less likely to endorse

cognitive-affective symptoms of depression, including dysphoria and worthlessness/guilt, than are younger adults

Older adults may be more likely than other age groups to present with

sub-syndromal depressive symptoms (SSD) that do not quite meet the DSM-5 (APA, 2013) diagnostic criteria for MDD. They may display less severe symptoms of depression that nonetheless interfere with daily functioning. In fact, SSD is associated with medical co-morbidities, suicidal ideation, healthcare use, and decreases in quality of life in older adults

The Stress and Coping paradigm developed by Lazarus and Folkman (1984)

has given us a framework to understand coping strategies. A key aspect of this model is that it is not the event itself that causes stress but how a person interprets the event. According to this framework, there are two ways an individual can cope with stressful life events

Problem-focused coping involves

using coping strategies that attempt to change the problem in some way.

Emotion-focused coping involves

coping strategies that deal with the feelings associated with the problem

If you apply the framework from a developmental perspective, two differences appear to emerge between

younger and older adults.

First of all, there is a difference in the type and amount of stress experienced as we age. Overall, older adults experience

less stress than younger or middle-aged adults and the source of the stress in older adults usually is due to health issues. On the other hand, stress for younger adults typically centres on work, finances, housing, pressure to succeed, and family

Another difference between younger and older adults in coping with stress is

the type of coping strategy used.

In general, the coping strategies younger adults tend to use are

more problem-focused coping strategies, where a direct approach is taken to change the event causing the stress.

On the other hand, the coping strategies older adults tend to use are

emotion-focused coping strategies, which include managing the thoughts and feelings associated with the event

Older adults engaged in significantly less habitual negative thinking than the younger adults, which led researchers to conclude that

this thinking style contributes to lower stress and the lower prevalence rates of depression found among older adults.

Older adults also are thought to be more selective in

who they spend time with. As we age, we become increasingly aware that we have a finite amount of time left on the planet. As a result, older adults want to spend more time with people that they positively interact with and avoid those individuals in which they share negative interactions with. This temporal perspective is the basis of the socio-emotional selectivity theory

Physical illness, in particular cardiovascular disease, stroke, and diabetes, can influence the development of

depression in older adults. Other factors that have been found to be related to the development of depression in late life include low social support and isolation, poor subjective health, recent bereavement and a change in residence

Conejero and colleagues (2019) believe that family physicians should be better involved in the prevention of suicidal behaviour in older adults. They found a strong link between physical illness and suicidal behaviour. Because physicians are often the first to have contact with older adults because of the higher prevalence of physical illness, they should be trained to

recognize suicidal symptoms. These researchers suggest that a sense of usefulness, feelings of social disconnectedness, and psychological pain associated with chronic physical illness should be assessed because of their strong association with suicidal behaviour.

Promoting and strengthening connectedness with family, friends, and community are important to

lowering the risk of suicide in older adults

The purpose of the Gatekeeper model is to

support the well-being and independence of older adults by educating laypeople in the community on how to identify at-risk older adults and refer them to an appropriate agency.

A combination of pharmacotherapy and psychotherapy are usually very effective in the treatment of depression, although some individuals benefit from psychotherapy alone. In terms of pharmacotherapy

selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and bupropion or mirtazapine (atypical antidepressants) are optimal initial treatment choices for depression in older adults

Physicians must be careful when prescribing any psychotropic medication to older individuals. This is because psychotropic medications may

interact with other medications, resulting in very serious side effects, as older adults are more susceptible to drug-induced side effects

Electroconvulsive therapy (ECT) has excellent efficacy for treating

severe depression in older adults. However, this typically is not used unless the individual does not respond to antidepressant medication. Adverse cognitive effects of ECT in this population are usually transient and not typically severe

Several meta-analyses and review studies have provided strong support for the efficacy of

cognitive behavioural therapy (CBT) as an individual therapy for depression in older adults

For older adults, modifications can be made to CBT such as

shortening sessions, presenting information at a slower pace, and involving family members if need be

Problem-solving therapy (PST)

which is another cognitive behavioural approach, has been adapted specifically to treat depression in older adults. In this type of therapy, older adults receive training in problem identification, problem-solving skills, formulating goals, evaluating the pros and cons of a potential solution, and then choosing an appropriate solution

Mindfulness-Based Stress Reduction

for reducing symptoms of anxiety and depression and improving memory and executive functioning.

The physical symptoms that accompany anxiety disorders can be debilitating and include

increased heart rate, sweating, dry mouth, chest pain, hyperventilation, diarrhea, insomnia, and headaches.

The majority of anxiety disorders in the older population have an onset at

an earlier age.

Screening for anxiety is difficult because differently aged people have different worries for instance

older adults tend to worry more about health issues and family-related problems

Anxiety can also be masked by

co-morbid medical conditions and medication side effects.

In addition, many older adults who have anxiety may not

recognize the symptoms they experience as anxiety and assume that it is a part of normal aging

A large percentage of older adults with GAD also have

depression and differentiating between the two disorders can be difficult

GAD specifically have found that this disorder is associated with

a higher risk of coronary heart disease, greater disability and functional impairment, and lower health-related quality of life

GAD in the older adult is also associated with

increased use of general and mental health services, increased conversion from mild cognitive impairment to Alzheimer’s disease, and increased psychiatric comorbidity and disability

When co-morbid anxiety and depression appear together, older adults suffer a more

chronic course of illness

Anxiety disorders in older adults are treated with medication as well as psychotherapy. Medication includes

SSRIs which are the medication of choice for both short-term and long-term treatment of anxiety disorders in general.

CBT for anxious older adults has been shown to be

an effective treatment as well as other interventions such as supportive discussion groups, and relaxation therapy

Virtual and remote mental health care, such as iCBT or video-based psychotherapies, are effective at improving

mild to moderate symptoms of anxiety, depression, and post-traumatic stress disorder in older adults

Worldwide, 3 million deaths every year result from harmful use of

alcohol, with this representing 5.3 percent of all deaths

79.2 percent of males 65 years and older self-reported past-year alcohol use compared to

62.7 percent of women 65 years of age and over

Moderate alcohol consumption is a protective factor for

many age-related diseases such as cardiovascular disease, stroke, and diabetes, and that moderate drinkers have better overall health than their heavier drinking and abstinent peers

The recommended daily consumption of alcohol for women is

no more than two standard drinks per day on most days or 10 standard drinks per week. The recommended daily consumption for men is no more than three standard drinks a day on most days or 15 standard drinks per week

Older adults become more sensitive to the effects of alcohol because alcohol is metabolized more slowly with age, which means it remains in the body longer The outcome of this for older adults is a higher blood alcohol concentration than younger adults for the same amount of ingested alcohol because

older adults also have less lean body mass, which results in less water available to dilute the alcohol that is consumed. Not surprisingly, the recommended amount of alcohol consumption is further reduced if you have comorbidities and consideration should be given to abstaining from alcohol consumption

There appears to be two patterns of alcohol abuse in the older adult population

one in which alcohol abuse started before the age of 60 and the other in which alcohol abuse started after the age of 60.

The latter is commonly known as

late-onset alcohol-use disorder. Those older adults who have been abusing alcohol before 60 years old appear to have a poorer outcome.

Typically, this group consists of males who have been abusing alcohol for a long period of time and, as a result, have burned bridges between family and friends. They also likely have

chronic physical impairments, alcohol-related medical impairments, and some level of cognitive impairment. Approximately two-thirds of older adult alcoholics fall into this category.

Heavy drinking also has been linked to

cardiovascular disease, dementia, high blood pressure, osteoporosis, cirrhosis of the liver, an inability of the body to properly absorb nutrients, and an increased injury from falls

Peak rates of hospitalization caused entirely by alcohol are highest for men between the ages of 55 and 69 and for women between the ages of 45 and 59. According to the report, in 2015–2016, alcohol-caused hospitalizations

exceeded hospitalizations caused by heart attacks in Canada.

55 percent of hospitalizations in individuals over the age of 65 are due to

misuse of medications, especially opioid medication which is used to control pain.

Older adults seem to do better in traditional treatment programs (e. g., Alcoholics Anonymous, motivational interviewing) that involve

age-appropriate care with healthcare professionals who are knowledgeable about aging issues

Psychotic disorders include abnormalities in at least one of the following five domains

delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behaviour (including catatonia), and negative symptoms.

Psychosis can be caused by

a psychiatric illness (primary psychosis) or a medical or neurologic condition (secondary psychosis).

Physicians first rule out any 

secondary causes of psychosis before considering the source of the symptoms to be a primary psychosis.

About 60 percent of psychotic disorders in older adults are due to

a medical or neurological condition (secondary psychosis)

Psychotic features occur in 20 to 45 percent of

older adults hospitalized for depression

A very common delusion in individuals who have Alzheimer’s disease is

that others are stealing from them.

If you can’t find an item because you can’t remember where you put it, you might think someone stole the item from you! The difference is

that you will eventually find the misplaced item. This is not necessarily the case when a person has memory deficits.

Delusions of infidelity are not

uncommon in individuals who have Alzheimer’s disease.

Another delusional disorder that has been observed in patients with Alzheimer’s disease and other dementias is called

Capgras syndrome.

Capgras syndrome

is a delusion in which the patient believes that a family member such as a spouse, sibling, or child has been replaced by an impostor.

The remarkable feature of a Capgras delusion is that patients are

able to recognize the related person’s face but believe that their relative has been replaced by a look-alike imposter

The most common type of hallucination in Alzheimer’s disease is

visual hallucinations and they typically involve intruders in the home as well as the presence of animals and deceased relatives

risk factors for psychosis

poor health status, cognitive problems, visual impairment, and negative life events.

Polypharmacy also may cause

psychotic symptoms in older adults

Males are much more likely to have the schizophrenia before the age of

40 and women are more likely to be diagnosed after the age of 60. These women were less likely to have children or a partner in the two years before diagnosis, suggesting to these authors that this group may harbour unrecognized psychiatric morbidity requiring clinical attention.

Participant responses could be divided into three categories

those who were optimistic and empowered by the improvements they experienced so far; those that experienced dismay over the discrepancy between their current situation and life goals; and those who were resigned to accept their current level of independence and functioning.

In this regard, new names have been proposed to replace the name schizophrenia such as

“Kraepelin-Bleuler disease,” “psychosis susceptibility syndrome,” and “Bleuler’s disease”.

Antipsychotic medications are associated with

adverse metabolic effects such as weight gain, an increase in cholesterol, and the onset of diabetes. Older age is also a risk factor for antipsychotic adverse effects such as Parkinsonism, tardive dyskinesia, and falls. As such, close monitoring of an older adult taking antipsychotic medications is needed

Antipsychotic medication is to reduce symptom burden but this doesn’t always

improve functioning.

Older adults can benefit as well as younger adults from psychosocial

skills training such as functional adaptive skills training, which aims to improve everyday life skills.

CBT, in combination with social skills training, has been shown to lead to

better skill acquisition and self-reported improved functioning in older adults with the benefits continuing at 12-month follow-up

The Collyer Brothers, Homer and Langley

were two wealthy and educated men who lived in New York City during the early 1930s. They became infamous for their extreme hoarding behavior, which led to their home being filled with an astonishing amount of clutter, including 120 tons of debris, a boat, 14 grand pianos, and over 3000 books. Their story highlighted the issue of hoarding disorder and brought significant media attention to it, especially after their home was discovered by the police.

Hoarding behaviours in childhood or adolescence often are described as

mild.

The prominence of severe symptoms tends not to occur until after age 40. These researchers suggest that severe hoarding symptoms (especially clutter in the home) take several years to develop because

the presence of others in the home (e.g., parents, spouse) limits the acquisition of items, assists with discarding items, and forces removal of the clutter.

Older adults may normalize their hoarding symptoms as they age, which would make hoarding hard to detect using

the self-report measures typically used to compare hoarding symptoms across the lifespan.

In addition to safety issues, hoarding disorder in older adults can have serious functional consequences such as

difficulty moving around the house, using appliances, or using the washroom. Rodent infestation and food contamination are common as is an increased risk for fire. In fact, if you search the Internet using the term “hoarders and fires” you will no doubt be amazed at the challenges that occur trying to fight a fire in the home of an individual with hoarding disorder! Because hoarding disorder is accompanied by safety and health challenges, it makes it very difficult for older adults to age in place, and many may face eviction by either landlords or environmental health agencies. In fact, Canadian researchers found that premature moving or eviction occurs for many older adults who hoard

Consortium has identified three types of animal hoarders

Overwhelmed Caregivers, rescuers, Exploiters

Hoarding treatment for older adults

Cognitive Behavioural Therapy shows promise as a treatment in several studies but attrition rates are high

Positive psychology

scientifically explores affirmative person-centred approaches to address the difficulties that people are challenged by and encourages people to use their personal strengths to deal with these difficulties

Positive psychology interventions

are effective for improving outcomes such as life satisfaction, psychological well-being, resilience, and hope. Also have been shown to decrease depressive symptoms and pessimism

Optimism predicted a lower risk of

stroke after controlling for chronic illnesses, sociodemographic, and psychological factors

Intervention in Hong Kong sought to develop and evaluate a custom-tailored positive psychology intervention program for older adults, and results showed that the intervention reduced the number of

depressive symptoms and increased levels of life satisfaction, gratitude, and overall happiness

Meaning-centred interventions such as forgiveness, gratitude, and altruism may be well suited to address

age-related decline and age-associated loss

Greater perceived savouring abilities, measured through self-report, are related to greater

resilience, lower depressive symptoms, and higher happiness in older adults" and Smith and Hanni confirmed these findings suggesting that "by increasing the duration, frequency, and intensity of positive emotions, savouring may contribute to the development of resources, such as strong relationships and skills that enable people to respond resiliently when challenges arise." This approach would seem beneficial no matter your age.

The best way to treat mental health issues in older adults is to take into account

the individual’s physical needs, as well as cognitive and functional status, when planning treatment interventions