Components of Assessment 1) Physical/Medical Situation 2) Mood/Affect 3) Support Systems 4) Level of Activity/Engagement 5) Coping Skills 6) Cognitive Status 7) Existential Concerns/Spiritual

PSYCHOSOCIAL ASSESSMENT OF OLDER ADULTS

PHYSICAL/MEDICAL SITUATION
Diabetes Cardiovascular Hypertension Arthritis Digestive Cancer COPD Macular Degeneration, Osteoporosis, Sensory Loss

ASSESSING LATE-LIFE DEPRESSION

Factors of Late-Life Depression 1) Loss of a spouse/close friends 2) Loneliness/Social Isolation 3) Increasing Disability/Independence 4) Co-existing Medical Problems 5) Cognitive Impairment 6) Loss of purpose 7) Decreased Financial Security 8) Demands of Care-Giving

Numbers of Depressed Older Adults

1-5 % - who live in the community 12% - who are hospitalized 14% - who require health care at home 29-52% - who live in nursing homes 39-47% - who are being treated for cancer, heart attack, or stroke. Often goes undiagnosed and untreated and viewed as normal part of aging.

Symptoms of Late-Life Depression

Somatic symptoms are more common than in other age groups, including heart palpitations, restlessness, fatigue, aches and pains, nausea and vomiting, dizziness, tremors, shortness of breath, fainting. Cognitive problems, including inability to concentrate or remember things. Mood disturbances, including irritability, anxiety, or preoccupation with death.

Why Symptoms of Late-Life Depression May Differ from Other Age Groups
Co-existing medical problems Medication side-effects Natural Aging Process Stigma more apt to report physical complaints.

Common Co-Existing Medical Problems

Cardiovascular Disease depression both predisposes people to vascular disease and to worsen outcomes. About 25% of people who have heart attacks suffer from depression. In one study, elderly people who were depressed were 4x as likely to die within four months of a heart attack than those without depression.

Common Co-existing Medical Problems (continued)

Dementia About 17% of people with Alzheimers also have major depression. Symptoms of depression may precede the development of dementia or Alzheimers. When depression and cognitive impairment develop simultaneously, the deficits may be mistaken for dementia or a problem known as pseudodementia. Cognitive function may improve if depression treated.

Treatment Options
Medication start low and go slow. 1)SSRIs ( Celexa or Prozac) 2)MAOIs seldom used in elderly due to concerns of side effects. 3)Maintain treatment 6 mos 2 years. These are all recommendations of the APA.

Treatment Options (continued)

Electroconvulsive Therapy 1) Most effective treatment for severe depression with psychosis. 2) Safe in older adults 3) Six to twelve treatments/2-3x per week

Treatment Options (continued)

Psychotherapy alone most effective for mild depression brought on by a stressful life change like retirement or loss of spouse. A combination of psychotherapy and medication may be most helpful for those with more severe depression.

 CBT Cognitive Behavioral Therapy aims to correct ingrained patterns of automatic negative thoughts and behaviors and learn how to cope better with problems. Supportive Therapy goal is to provide reassurance and hope. Interpersonal Psychotherapy creates a human bridge between older adult and therapist to identify new ways to engage in life.

Types of Psychotherapy Most Effective for Late-Life Depression

Types of Psychotherapy(cont)
Reminiscence Therapy/Life Review widely accepted only in geriatric counseling. All other fields try to keep client focused on the present time. Goal is to assist older clients to put purpose and meaning to their life experiences by active reminiscence of past achievements and failures. Helps re-establish ego integrity. Builds a deeper level of trust and comfort with therapist. Allows a person with mild cognitive impairment to put aspects of their current situation in order.

Types of Psychotherapy(cont)
PST-Problem Solving Therapy goal is improve coping skills by identifying a problem, considering options, making a decision to try something, and re-assess and then consider new options. Research conducted with 206 people newly diagnosed with AMD indicates those who received PST were only half as likely to have developed depression after two months.

Positive or Well-Being Psychotherapy

Based on Carl Rogers humanistic clientcentered therapy. Similar to Maslows traits of the self-actualized individual. Seligman, Carol Ryff, Carl Kaufman, and George Valliant are all associated with PPT Positive Psychology Therapy. Sometimes dismissed as happy talk is becoming an important and effective way to treat late-life depression.

Goals of PPT
M. Seligman (U. of PA) to understand what makes life worth living and to build on personal strengths. Build whats strong and fix whats wrong. Carol Ryff uses a multidimensional model of subjective well-being consisting of six tenets: mastery of environment, personal growth, purpose in life, autonomy, self-acceptance,and positive relationships. Much like CBT. Challenges negative ways of thinking to enable positive events to have more of an impact on clients life.

Goals of PPT(cont)
Carol Kauffman (Harvard) Four techniques of PPT including: 1) Reverse focus from negative to positive 2) Develop a language of strength 3) Balance positive and negative. 4) Build strategies that foster hope.

Goals of PPT(cont)
George Valliant (Harvard) PPT is a way for clients to focus on positive emotions, build strengths, supplementing traditional psychotherapy that focuses on negative emotions like anger, fear, shame, guilt, and terror, and sorrow. Standard psychiatric textbooks do not discuss hope, joy, love, compassion, courage, strength, curiosity, zest, or wisdom. Other researchers: Cawthon (U. of Utah), Ostir, et.al, (U. of Texas)

Depression Management Systems

Evidence-Based Practices 1) IMPACT: Improving Mood: Promoting Access to Collaborative Treatment 2) STAR*D Sequenced Treatment Alternatives to Relieve Depression 3) PATCH Psychogeriatric Assessment and Treatment in City Housing 4) PEARLS a PST program teaching coping skills.

Diagnosing Dementia
DSM-IV impairment in memory and at least one other area of cognitive deficit 1) abstract thinking 2) judgement 3) aphasia forgetting words 4) apraxia movement 5) agnosia naming things 6) constructional ability 7) orientation to time, place, person

Major Types of Dementia

Reversible Brain tumors, depression, nutritional deficiencies, drug toxicity, alcoholism, hypo/hyper thyroidism Irreversible Alzheimers disease, vascular, Huntingtons disease, Creutsfeldt-Jacob, Korsakoff syndrome, B-12 deficiency Most common irreversible dementia is Alzheimers disease 50-70% of all dementias.

Alzheimers: The Facts

An estimated 5.1 million Americans currently have Alzheimers, including 4.9 million people age 65 or older or 10%. Rate of Alzheimers doubles each decade after 65 reaching 50% in those 85+. Some 10 million baby-boomers will have Alzheimers. By 2030, the number of Americans with Alzheimers is expected to increase by more than 50% to 7.7 million. The direct and indirect costs of Alzheimers and other dementias total more than $148 billion annually.

Diagnosing Alzheimers Disease

A 7-12 year chronic, progressive, incurable illness which destroys brain cells which effect memory, reasoning, and behavior and robs people of intelligence, social skills, personality, awareness, ability to control bodily functions, and kills. Must differentiate from depression and delirium both of which are more acute. No blood test diagnosis is one of exclusion, not inclusion Physical, neurological, cognitive, and mental status exams(MMSE-Folstein) and GDS(Reisberg

Risk Factors
Neurochemical systems break down resulting in the loss of acetylcholine-a chemical messenger which transfers information from one cell to another. Lack of estrogen Increased levels of amyloid proteins in the brain # of siblings Area of residence Early life head injury/sleep apnea ApoE-4 a variant of a gene on chromosome 19 carried by about 30% of population.

Symptoms/Stages of Alzheimers
Early stage inability to recall a recent event, inability to take in new information, repeat questions just answered, leave an everyday task unfinished, mild forgetfulness, concentration problems, difficulty at work and traveling alone. Middle stage increased problems in handling finances, withdrawal, denial of symptoms, bathes with reminders, need reminders about appropriate clothing, irritability, anxiety, depression, delusions, delirium, wandering. Long-term memory, judgement, concentration, orientation and speech all become impaired. ADL probs.

Symptoms/Stages(cont)
Advanced Stage significant memory problems, personality changes, assistance with ADLs, cannot understand or use language, does not recognize family members, cannot eat without help, cannot control bowels/bladder, loses ability to walk, sit-up, or swallow food. May become comatose. Death within 8-10 years.

Assessing Alzheimers Patients and Their Families

Effective care for a person with dementia includes: 1) The neuropsychiatric evaluation using the sequence of a Johns Hopkins Phipps history 2) A thorough family assessment whose importance cannot be overemphasized. 3) A realistic, dynamic, anticipatory, comprehensive treatment plan that conveys hope and supports care-givers.

Family Concerns at Each Stage of Illness

Early Stages understanding the diagnosis/prognosis, supervision and safety, driving, competency, financial planning Middle Stages Management of behavioral problems, sexuality, finding respite care, isolation, fatigue due to constant supervision. Advanced Stage Nursing home placement or home-care, artificial feeding or hydration, end of life decisions, autopsy. Issues after death Unanticipated grief, back to daily routines, genetic counseling, recovery

Non-Pharmacological Care
Early Stage 1) Set up an orientation area at home for wallet, keys, glasses, etc. 2) Encourage physical and social activities. 3) Encourage good nutrition and sleep. 4) Watch for driving problems. 5) Activities the person enjoys.

Non-Pharmacological Care
Middle Stages 1) May have to make changes in the home to assure safety and independence, but maintain familiarity, like improved light levels. 2) Label drawers and doors. 3) Keep photos on tables and names on them.

Non-pharmacological Care
Advanced stages 1) Visit long-term care facilities 2) Simplify daily routines walk in the yard stay active. 3) Use alternative ways to communicate, like touch or sharing photos. 4) Assess for pain

Helping Families Cope

On-Going Education help caregivers anticipate changes and behavioral disturbances Supportive Counseling Individual problemsolving, support groups Referral to community resources- to obtain DMPOAs, financial advice, information on longterm care facilities. Plan of care should maximize quality of life for both patients and families.

Attitudes of Elderly Toward Death

Research indicates older adults are significantly less fearful of death than younger persons. Older adults more frequently fear disability, being alone or socially isolated, being dependent, or being psychologically isolated. Older adults need to: 1) Maintain personal integrity/sense of self 2) Participate in life decisions 3) Know their lives still have value 4) Receive appropriate/adequate health care

Hospice Positive Dying

Not a place, but a philosophy of care providing physical, medical, emotional, and spiritual care to patients and their families. Dedicated to pain reduction and maintaining personal dignity, in addition to ensuring quality of life until death. Respite care for families Psychological, social, and spiritual counseling for patients and their loved ones. Coordination of services with home health, hospitals, and nursing homes

Bereavement in the Elderly

Grief reactions are more somatic than psychological No variation in the intensity of grief Grief may be longer Loneliness is more intense and for a longer period of time.

Addictions in Older Adults

Upward trend of older adults abusing pain medications and other opiates. (SAMHSA, 2005) Alcohol remains most abused substance, yet there has been a decline in reported admissions from 86.5% in 1995 to 77.5% in 2002. Many elders are overusing and misusing alcohol to cope with difficult life changes. Diagnosis of alcohol/dependence/abuse is seldom made in older adults. Left unaddressed, an older person is vulnerable to addiction, resulting in more acute medical

What To Look For

Unexplained bumps, bruises, and falls Memory loss, blackouts, vague recollections Depressed mood, anxiety, hostility Isolation or withdrawal Drinks in spite of warning labels Smell of liquor or mouthwash on breath Self-neglect

Treatment for Substance Abuse in Later Life

More education on disease of addiction People who are addicted are not bad people who need to get good, they are sick people who need to get well. Treatment outcomes for older adults (with later onset) have high recovery rates. Reduce isolation and help develop social supports. AA

Compulsive Gambling
Since 1974, the highest increase in gambling has been along adults age 65+ Third and 4th days of month are busiest at casinos Easier access to lottery tickets Older persons are at risk for losing everything with no resources to start over. One in 3 compulsive gamblers is a woman. Compulsive gambling increases risk for suicide

Treatment for Gambling

Difficult to treat, but treatable Few professionals screen for gambling Individual, group, and family counseling Gamblers Anonymous Education about compulsive gambling

Conclusion
Give respect Help maintain dignity and personal integrity Assist in giving value to their lives Understand their uniqueness Treat what improves quality of life Build whats strong and fix whats wrong.