Mental Health & Care of Older Adults

Lecture 7October 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?

• 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• Loss of interest and pleasure• Feelings of worthlessness or guilt• Diminished ability to think• Thoughts of death or suicidal ideation

2) Physical symptoms• 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

Wrosch et al. (2004). Health stresses & depressive symptomatology in elderly adults: A control-process approach. Current Directions in Psychological Science. 13(1), 17-20.

Health Stresses and Depression

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 future1. 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:

– <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• 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, Beta-amyloid, 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 control3.Physical dependence4.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• 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

• 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?