Transcript Mental Health & Care of Older Adults

Mental Health & Care of Older
Adults
Lecture 7
October 31st, 2007
Tonight’s Topics
• What are the mental health issues facing
older adults?
• Is depression inevitable in older adults?
• How can depression be addressed?
• Dementia and its misconceptions
• How do older adults adapt and cope with
the environment around them?
• What factors help adaptation to a new
environment such as a nursing home?
What Characterizes Mental Health?
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Positive attitude toward self
Accurate perception of reality
Mastery of the environment
Autonomy
Personality balance
Growth and self-actualization
• Pathology:
– Behaviors become harmful to oneself or others.
– Lower one’s well-being.
– Perceived as distressing, disrupting, abnormal, or
maladaptive.
Are There Differences Pertaining to
Mental Health in Older Adults?
• Some behaviors considered abnormal
under the preceding criterion may be
adaptive for many older people
– Isolation
– Passivity
– Aggressiveness
• Such behaviors may help older persons
deal with their situation more effectively.
• If adaptive: Not distressing, which is key in
diagnosis of mental health issues
How Do Biological Forces Influence
Mental Health?
• Health problems increase with age
• Evidence supports a genetic component to
Alzheimer’s
• Physical problems may present as
psychological and vice versa
• Irritability  thyroid problem
• Memory loss  vitamin deficiencies
• Depression  changes in appetite
Do Psychological Forces Have An
Influence on Mental Health?
• Normative age changes can mimic certain
mental disorders.
• Normative changes can mask true
psychopathology.
• Look to nature of relationships as key to
understanding psychopathology.
• Young  expanding relationships
• Old  contracting relationships
What Are The Sociocultural Forces
Influencing Mental Health?
• Sociocultural forces
– Paranoia or healthy suspicion?
– Look at differences according to location
• Differences in ethnicity?
– Recent immigrants: Lack of access to
mental health services
– Differences: Canadians of Asian/South
Asian/African vs. English vs. Jewish
How Do We Assess Mental Health?
• Elements of Assessment
– Measuring, understanding, and predicting
behavior
– Gathering medical, psychological, and
sociocultural information
• How?
– Interviews, observation, tests, and clinical
examinations
All About Assessment
• Two central aspects
–Reliability
–Validity
• Psychological areas of examination:
–Intelligence tests, neuropsychological and
mental status examination
–Mini Mental State Exam
What Factors Influence Assessment?
• Professionals’ preconceived ideas have
negative effects
– Biases: Negative and positive
– Environmental conditions
• Sensory or mobility problems
• Health of client
What Are The Treatments Available?
• How to treat the client
– Medical Treatment
• Psychotropic and other drugs
– Psychotherapy
• Single or group talk therapy
– APA criterion
• Well-established
• Probably efficacious
What is Depression?
• Beliefs pertaining to depression vary across
cultures.
• Lawrence et al. (2006): UK study looked at Black
Carabbean, South Asian, and White British older
adults.
• All 3 groups believed it was a serious condition.
• WB used the biomedical model of depression
whereas SA participants were more liekly to see
it as a normal byproduct of sadness or grief.
• WB & BC defined in terms of low mood and
hopelessness. BC and SA also put in terms of
worry.
How Do Psychologists Define
Depression?
1) Dysphoria – feeling down or blue
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Loss of interest and pleasure
Feelings of worthlessness or guilt
Diminished ability to think
Thoughts of death or suicidal ideation
2) Physical symptoms
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Insomnia/hypersomnia
Fatigue
Weight loss/gain
Agitation/psychomotor retardation
3) Symptoms must last for at least 2 weeks.
4) Other causes for observed symptoms
must be ruled out.
5) How are the symptoms affecting daily
life?
• Clinical depression involves
significant impairment in normal living.
What Do You Think?
• Can we equate being older with being
more depressed?
• Can older adults get better if they are
depressed or are they unable to change?
Myths Concerning Depression In
Older Adults
• Depression is a normal state of affairs as
one gets older.
• It doesn’t need to be treated.
• Older adults don’t want therapy.
• Older adults can’t change with therapy.
• The ratio of benefit to cost is too low.
Prevalence of Depression
Gender and Depression
• Women diagnosed as suffering from
depression more often than men
– Life satisfaction & depression
Early vs. Late Onset Depression
• Late-onset depression: 1st episode after
60 years old
• Van den Berg et al. (2001) found 3
subtypes: EO, LO with severe life stress &
LO without severe life stress
• EO: Associated with neuroticism &
parental history of depression
• LO without stress: Higher vascular risk
factors than those with LO with stress.
Early vs. Late Onset Depression
• Joost et al. (2006) screened a large group
(n=3107) of older adults to find individuals with
early onset (n=90) or late onset of depression
(n=39).
• Early onset and genetic vulnerability vs. late
onset and vascular pathology?
– Not found in this study
• LOD: Being widowed (not recent loss), having
poorer cognition, being older
• EOD: More comorbidity with anxiety
• Found no difference between the 2 groups in
terms of levels of disability
Health Stresses and Depression
Wrosch et al. (2004). Health stresses & depressive symptomatology in elderly adults: A
control-process approach. Current Directions in Psychological Science. 13(1), 17-20.
Depression and Mortality
• Schulz et al. (2000)
• Is depression related to mortality?
• High levels of depressive symptoms: 25%
more likely to die within 6 years.
• Model to explain the interaction between
depression & death.
Depression and The
Cascade to Death
What Tools Can We Use To
Assess Depression?
• Beck Depression Inventory
– Feelings and physical symptoms
• Geriatric Depression Scale
– Physical symptoms omitted
• Both more accurate with women than
men.
Beck Depression Inventory (BDI-II,
1996)
• 21 statements, each with 4 possible answers.
Circle the statement that most represent how the
respondant has felt in the last week.
• Sample item:
0. I am not discouraged about my future
1. I feel more discouraged about my future than I
used to be.
2. I do not expect things to work out for me.
3. I feel my future is hopeless and will only get
worse.
More About The BDI
• Scoring:
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<10: Normal mood
10-15: Minimal depression
16-19: Mild to moderate
20-29: Moderate to severe
30 and +: Severe depression
• Face validity is very apparent, which makes it
easier to dissimulate symptoms.
• Not designed specifically to evaluate older
adults however…
Geriatric Depression Scale
(Yesavage et al., 1983)
• Yes/no questions.
• Short (15 items) and long (30 items) forms
• Short form to minimize fatigue, but
correlation is only 0.66 between the 2
forms.
• e.g.: Are you basically satisfied with your
life?
• Have you dropped many of your activities
and interests?
What Are The Causes of
Depression?
• Biological focus
– Genetic predisposition
– Neurotransmitters
• Norepinephrine
• Serotonin
• Psychosocial focus
– Loss and bereavement
• Behavioral and cognitive-behavioral
theories, a different approach.
Treatment of Depression
• Severe forms of depression
– Electroconvulsive therapy – ECT
• Less severe forms
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Prozac, Zoloft: SSRI
Tricyclics
MAO inhibitors
Lithium (bipolar disorder)
Satre et al. (2006) Article on CBT
• What is CBT? Modifying thoughts and
behaviours to influence emotions.
• Article integrates findings about social and
cognitive changes, cohort differences,…:
Adapt the model to these changes.
• Efficacy of CBT = medications, but less
likely to relapse
• Can address depression, anxiety,
substance abuse, insomnia,…
What Is Delirium?
• Disturbance of consciousness and change in
cognition developing over a short period of time.
• Fluctuation in impairment over time, unlike most
dementia.
• Individuals tend to recover within a few
hours/days, although older adults are at risk for it
to persist longer.
• Caused by:
– Stroke, cardiovascular disease, metabolic
condition, medication side effects, substance
intoxication or withdrawal, exposure to toxins,
or combinations of the above
Alzheimer’s Disease: A
Daughter’s Experience
Dementia
• Affects 6 – 8% of people over 65
• Bad news: 50% of people over 85 have
dementia.
• Good news: 50% don’t!
• Because more people are living to older
age, the number with dementia is also
increasing.
DSM-IV Criteria to Diagnose A.D.
1. Memory impairment + one of the following:
aphasia, apraxia, agnosia & disturbance in
executive functioning.
2. Represent a significant change in functioning.
3. Gradual onset and continuing decline.
4. Not due to other physical illness or substance.
5. Do not occur during the course of delirium.
6. Do not represent another Axis-I disorder.
Characteristics of Alzheimer’s
disease
• Accounts for 70% of all dementia, although
mixed dementia with vascular features
becoming more commonly recognized.
• Neurological changes in Alzheimer’s disease
• Microscopic
• Rapid cell death in hippocampus, cortex, basal
forebrain
• Neurofibrillary tangles (tau protein)
• Neuritic plaques (Beta-amyloid protein)
• Is Alzheimer’s merely an exaggeration of normal
aging?
What Might Be The Causes of AD?
• Neurotransmitters: Acetylcholine,
serotonin
• Cellular changes: Phospoholipids, Betaamyloid, tau protein
• Genes: Chromosome 19: ApoE4
• Metabolism: Glucose & oxygen changes,
calcium
• Environment: Aluminum, zinc, food toxins,
viruses
Early Onset vs. Late Onset?
• Late onset is probably due to combination of
factors previously mentioned.
• Early-onset Alzheimer's may be caused by
genetic mutations
– Autosomal dominant pattern – chromosomal
causes
• Pick’s disease
• Huntington’s disease
• Down’s syndrome (Chromosome 21-similar changes
with beta-amyloid as AD; Chromosomes 1 & 14 as
well)
Are There Interventions Possible?
• Intervention strategies
• Caring for patients with dementia at home
– Caregivers have significant problems
• Effective behavioral strategies
– Differential reinforcement of
incompatible behavior (DRI)
– Arguing with patient is
counterproductive
• Respite care and adult daycare
Other Forms of Dementia
• Other forms of dementia
– Vascular Dementia – CVA (stroke)
– Frontotemporal Dementia (FTD)
– Parkinson’s Disease
• Associated with dopamine deficiency
• 14% to 40% will develop dementia
– Huntington’s Disease
• Associated with GABA deficiency
– Alcohol Dementia Complex
• Wernicke-Korzakoff’s Disease
– AIDS Dementia Complex (ADC)
Are There Other Mental Disorders
Fairly Prevalent in Older Adults?
• Anxiety Disorders
– Symptoms and diagnosis of anxiety
disorders
– Treating anxiety disorders
• Drugs – Valium, Librium, Serax, Ativan
• Psychotic Disorders
– Schizophrenia
– Treating schizophrenia
Substance Abuse in The Elderly
• Prescription & over the counter (OTC)
• Alcohol abuse – Four symptoms
1.Craving
2.Impaired control
3.Physical dependence
4.Tolerance
• Left untreated, alcohol dependency
does not improve over time
How Are Person-Environment
Interactions Described?
• Kurt Lewin (1936) came up with a formula
to describe them.
• B = f(P, E)
Where:
• B = Behavior
• P = Person
• E = Environment
Competence & Environmental Press
• Competence is the theoretical upper limit of a
person’s capacity to function.
• Five domains of competence (Lawton &
Nahemow, 1973)
– Biological Health
– Sensory-perceptual functioning
– Motor skills
– Cognitive skills
– Ego strength
• Environmental Press: Environments can be
classified on the basis of the varying demands
they place on the person.
– Interactions between physical, interpersonal &
social demands.
The Congruence Model
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According to Kahana’s (1982) congruence
model, people with particular needs search for
the environments that meet them best
Can you think of examples?
1. A person without personal transportation
seeks a house near a bus route.
2. A handicapped person needs a home
adapted to a wheelchair (no steps).
3. An elderly person may need to relocate to
an assisted-living facility.
Stress & Coping Framework
• Interaction with the environment can produce
stress (Lazarus, 1984)
• Evaluating one’s situation and surroundings
for potential threat value
– Harmful
– Beneficial
– Irrelevant
• If harmful, what is the coping mechanism and
response? Outcome positive or negative?
The Loss Continuum Concept
• Loss continuum
– Children leaving
– Loss of social role
– Loss of income
– Death of spouse/close friends and relatives
– Loss of sensory acuity
– Loss of mobility accompanied by
– Loss of health
Common Theoretical Themes and
Everyday Competence
• Everyday competence is a person’s
potential ability to perform a wide range of
activities considered essential for
independent living.
• Broader than just ADL or IADL.
• Necessary determinate for whether an
elderly person can take care of
themselves.
What Types of Long-Term Care
Facilities Are There?
• Nursing homes (most prevalent but costly)
• Assisted living
• Adult family homes
Who is Likely to Live in Nursing
Homes?
• Characteristics of People Most Likely to Be
Placed in a Nursing Home
– Over age 85
– Female
– Recently admitted to a hospital
– Lives in retirement housing rather than being a
homeowner
– Unmarried or living alone
– Has no children or siblings nearby
– Has some cognitive impairment
– Has one or more problems with IADL
How Are Residents Interacting with
Nursing Home Environments?
• Congruence Approach (Kahana, 1982)
– Personal well-being depends not just on
facilities, but on congruence of person’s
needs and the ability of the facility to meet
those needs
– 80% of nursing home residents perform
below their personal ability because of the
lowered expectations of the staff.
How Are Residents Interacting with
Nursing Home Environments?
Moos’s Approach
• MEAP scales evaluates facilities in the
following four aspects:
– Physical and architectural
– Organizational and administrative staff and
policies
– Supportive characteristics of staff
– Social climate
How Can Competence Be Promoted
in Residents of Nursing Homes?
• Is the medical model best (Langer & Rodin,
1976)?
– No. Langer showed that residents who were
encouraged to make choices in daily activities
were feeling better and were more active.
• Mitigation factors:
– Decision to enter NH usually not made by the
individual
– “Nursing home resident” and “patient” has
negative connotation
– Being overly helpful may actually harm the
residents by making them more dependent than
need be.
– Strict routine is detrimental to well-being.
Problematic Forms of
Communication With Residents
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Patronizing speech
Infantilization or baby “talk”
Inappropriate use of first names
Terms of endearment “Honey” “Sweetie”
Assumption of greater impairment than
may be the case
• Cajoling to demand compliance
Decision-Making Capacity and
Individual Choices
• How well can a nursing home resident
make decisions regarding their care?
– Cognitive impairment
– Name a substitute decision-maker for
health and/or monetary concerns
– Provide written information at time of
admission concerning their right to make
treatment decisions
– Living will
Article by Lai & Karlawish (2007)
• How do you assess the capacity of an
older person to make decision, especially
if they have a cognitive impairment?
• Why is the current way of making
decisions problematic?
• What criteria should be used to decide
whether someone can make autonomous
decisions?