Health in Later Life
What is Normal Ageing?
Gerontology is the study of aging, that while most people want to live a long time, no one wants to get old
Key principles in gerontology:
Differences in Primary and Secondary Aging
Primary aging reflects changes in the organism that are a result of the passage of chronological time
Over time, many parts of our physical psychological and social make-up will change; this happens to everyone.
For example, visual acuity declines and so most people need ready glasses to read print after a certain age. This happens as one’s ability to focus short distances declines with age
Changes that are due to aging are due to a specific disease process or a result or trauma, or lifestyle choices.
Only 6% of people over 65 have dementia. This risk can be lowered however, unlike primary aging
Heterogeneity
Increases with age, making older adults a great population to study because there’s a lot of variance in the population
Cohort Effects
When people who have been born in a certain period of time and gone through a certain set of experiences will tend to share a relatively similar outlook
Best way to answer questions about changes in people over time, with age, is to do a longitudinal study = asks the same people questions over time, measures changes in physiology or behaviour over many years of time
WHO’s Definition of Health
goes beyond physical health to encompass “a complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity”
This holistic principle of care underlies the best practice care principles of those who care for older, or geriatric patients.
Some examples of later life health care professionals include geriatricians — physicians who specialise in later life medical care — and geriatric psychologists, or geroplychologists, like myself
Mental Health in Later Life
Older adults in the general population have about a 15 to 25 % chance of having a serious mental illness compared to a 20% in the general population
Older adults show more variance partly due to them being more heterogeneous as a group and whether or not they are in a nursing home.
People in nursing homes make up 6-7% of the population but 70-90% of that nursing home population have either a psychiatric condition, and/or dementia.
The chance of having a diagnosable psychiatric condition decreases with increasing age, however dementia risks increases
The majority of older adults, whatever setting they live in, are neither assessed nor treated for psychiatric disorders.
In a study, Helmes and Gee presented psychologists with a vignette of a depressed patient and manipulated their age.
The client was described as a white female patient and describing symptoms to her psychologists included tearfulness, loss of interest in activities, early morning awakening, and weight loss.
The two versions were 42 or 72 and both ages received a diagnosis of depression, however the older client was described as having a poorer prognosis as being less able to develop an adequate therapeutic relationship with the therapists, and ultimately less appropriate for therapy. The therapists also felt less competent and less willing to accept the older client — ageism
Depression and Anxiety in Later Life
Depression and anxiety present differently in older people than when they occur in earlier life, which leads to a frequent misdiagnosis of dementia
For example, a patient with depression in their later years may talk about feeling less able to enjoy their favourite activities, or talk about decreased appetite and weight loss, but they will usually emphasise difficulties in remembering common things such as items at the grocery store, or a good friend’s telephone number.
Key risk factors for depression include: disability, newly diagnosed medical illness, poor health status, poor self-perceived health, prior depression, and bereavement.
Protective factors include greater perceived social support, regular physical exercise and higher socioeconomic status.
Older adults are less likely to get a thorough work-up and are less likely to be offered the widest range of treatment options compared to younger adults
Anxiety is actually more common later in life when compared to the incidence of depression in later life. Many risk factors are the same for both anxiety and depression.
Key risk factors for anxiety include poor self-rated general health status, physical or sexual abuse in childhood, and being a current smoker.
Protective factors include greater perceived social support, regular physical exercise, and higher level of education.
Both socioeconomic status and education are really reflective of economic resources. And research shows greater resources confer greater protection against both depression and anxiety, at all ages.
Therapy in Later Life for Depression and Anxiety
Cognitive behavioural therapy, relaxation training, and support therapy help older adults with anxiety
In CBT the emphasis is on making explicit links between how you are thinking and behaving, and how you are feeling. It teaches patients to pay attention to shifting negative thoughts and behaviours to shift their emotions in a positive direction
Relaxation training is very useful to combat anxiety at any age — involves improving, reinforcing, or sustaining a patient’s physiological well-being or psychological self-esteem and self-reliance
Older adults in many surveys expressed a distinct preference for psychotherapy over medication, especially if they already have a physical illness which requires medication. Avoiding polypharmacy, or multiple medications where possible, helps decrease the chance of adverse medical reactions or side effects in older people.
Interpersonal psychotherapy, problem-solving therapy, and brief psychodynamic psychotherapy help older adults with depression
Interpersonal psychotherapy (IPT) is a highly structured and time-limited therapy approach that focuses on helping the patient to resolve interpersonal problems, which are thought to underlie depression
Problem-solving therapy is a form of CBT is aimed at improving an individual’s ability to cope with stressful life experiences, and improve depressed or anxious mood. In this approach the therapist tries to give the patient more positive coping strategies to replace those which may be unhelpful or maladaptive
Psychodynamic therapy include increased client self-awareness and improved understanding of the influence of past experiences on present behaviour. This is a time-limited intervention which, while focused on past experiences, is nevertheless oriented to current goals such as better coping with anxiety or depression
Interdisciplinary treatment models are highly effective with older persons, particularly those with complex mental illnesses and dementia. This usually involves a physician, nurse, psychologist, and other allied health professionals such as occupational therapists, physical therapists, and social workers. They are both effective in treating complex long-standing psychiatric conditions such as schizophrenia, memory clinics where the source by by from physical or psychiatric causes, or end of life treatment in cases of terminal illness
Psychosis and Bipolar Disorder in Later Life
Older adults with such issues did not, and to a certain extent still may not, receive the support they need to maintain functionality and quality of life
Importantly, both current and past diagnostic criteria for psychosis and related disorders also remain problematic for older people. For example, the research on whether presentations of schizophrenia and bipolar disorder differ at different ages of first onset is still lacking.
Both disorders are relatively rare in later life. 75% of older patients with schizophrenia will have experienced the onset of the disorder in early and mid-life, and 25% in later life
Older bipolar patients can appear similar to older patients with schizophrenia in terms of their levels of disability and functioning in the community.
People psychoses also learn from their experiences about how to manage the illness and avoid distressing relapses. Coping strategies also appear in some studies, to evolve and improve with age, however a lack of treatment for those with schizophrenia in later life increases their risk of nursing home placement.
Therapy approaches often target areas of everyday functioning—medication management, social skills, communication, organisation and planning, transportation, and financial management
In working with older adults with chronic mental illness, drawing on their past experience of how they have come to understand their illness and what they have learned from past treatment efforts, both positive and negative, is a rich resource for intervention
What is Dementia?
Forgetting simple things, like where your keys are, is a normal part of aging. If you put keys into a dementia patient’s hand, they wont even know what they are for.
Alzheimer’s disease is a kind of dementia and the most prevalent, between 50-70% of all dementias can be attributed to Alzheimer’s disease
Dementia characterised by changes in memory, thinking, personality, and behaviour, and can manifest in different symptoms. Also involves intellectual impairment and language and executive functions such as goal setting can be affective
A good definition is that it is an acquired syndrome of intellectual impairment produced by brain dysfunction
Early onset can be in your 30s and 40s. Most form of dementia are inheritable.
Lifestyle risk factors can be much more influential than your genes, such as smoking.
Dementia signs can be subtle but they usually develop quickly—if you cannot remember things, even when people remind you or give you hints, that is more likely to be dementia
What is being processed within the brain is no longer reliably stored in the brain, due to cellular changes in the brain resulting from the disease process.
People with dementia can have really big changes in personality—someone introverted can become suddenly extroverted or vice versa
Incidence of Dementia
The estimated number of people to be living with Alzheimer’s disease and dementia stands at between 27-36million, with increasing financial and social costs
Two thirds of people with dementia are estimated to be living in the developing world, where access to diagnosis and treatment is underdeveloped
10% of less of population-based research on dementia has been carried out on the two thirds, or 66%, of people with dementia live in low and middle income countries
Dementia is the most common age-related cognitive condition among Aboriginal peoples worldwide
Caring for Dementia Patients
The cells in the brain die as a result of dementia, and we have no way to halt this even though Alzheimer’s has been studied for over a hundred years
People with dementia don’t usually die due to the disease, they die of other related diseases like a stroke or pneumonia, usually between 8 and 10 years after diagnosis
Interventions include various activity based therapies to keep with dementia stimulated, as well as supportive therapies to help those with dementia with symptoms of depression or anxiety
Environmental approaches help to make living spaces easy to navigate and homelike
Kitwood’s person centred care model involves having the focus of care on the person, not fulfilling tasks or just attending to the person’s physical health needs
Person centred care includes every sort of interaction with the person with dementia. It is a very specific intervention, and importantly includes how medical or health care is given
Innovative Technology in Aged Care
One area of technological development is helping innovate care delivered to older patients: age specialised health care settings. This will in part encompass rethinking how health care services are organised and delivered, with geriatric surgical centres and emergency rooms already in place.
Staff in such setting undergo specialised training, and the environment, instruments, tests performed, and interventions used are all designed specifically with older adults in mind, to translate what is known about best standards of geriatric care into practice
Netherland’s town for dementia patients
Designing to be age-friendly
World Health Organisation has developed an age-friendly cities and environments program. It is aimed at positively affecting the health and wellbeing of older adults by ensuring that the physical and social aspects of their living environments support their needs. Eight dimensions of the living environment are targeted:
the built environment, transport, housing, social participation, respect and social inclusion, civic participation and employment, communication, and community support and health services.
The WHO Global Network of Age-Friendly Cities and Communities was established. Communities in the program range from very large cities to relatively smaller cities. This guide is informative for anyone wanting specific knowledge about avenues of potential improvement to the living spaces older adults inhabit.
Dementia and Pets
For many people in aged care who may not be able to keep their own animal, interactions with visiting or on site animals are very important.
All of these environmental enrichment principles can help with good mental health in the nursing home.