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Net maintains responsibility for this program and its content. Net maintains responsibility for the program. Social workers should contact their regulatory board to determine course approval. Course format distance learning - online activity. Programs that do not qualify for NBCC credit are clearly identified.

Net is solely responsible for all aspects of the programs. This is a beginning to intermediate level course. After taking this course, mental health professionals will be able to:. This course on aging is intended for all clinicians wanting to understand the mental health problems of older adults, most who are using professional care.

The United States is facing the largest change in demographics in the history of humankind. People over 55 are now the largest segment of our society, comprising 21 percent of the total population. Those over 65 are now the fastest growing segment of our population. According to the US Census Bureau, the number of Americans aged 65 and older grew from about 3 million in to over 35 million in During that period, the ratio of those over 65 to the total population jumped from one in twenty-five to one in eight.

By , the number of people over 65 will reach 85 million. The elderly will outnumber children by in most of the world. Worldwide, the number of people over 65 is increasing at about , every month. What is more important is the finding that within the over group, the fastest growing segment is those over By , 1 in 26 Americans can expect to live to age , compared to 1 in in During this time, the number of older Caucasians will increase by 97 percent, African Americans by percent, and Latino Americans by percent.

Ethnicity will be an important variable in treatment some cases. As the boomers are growing up, breakthroughs in public health, sanitation, nutrition, and medicine have led to an unanticipated increase in life expectancy, and an unprecedented increase in the number of elder Americans. This change was brought about primarily by the establishment of clean drinking water and public sanitation systems, along with the discovery of antibiotics.

However, deaths from pneumonia and tuberculosis declined from about per , in to only 60 per , in As of , ischemic heart disease, stroke, lower respiratory infections and chronic obstructive lung disease.

Because of the rapid improvement in medical technology and treatment options, these problems are less life threatening, and life expectancy is predicted to increase even more in the next twenty years. Because of this meteoric rise in lifespan, dementing illness has increased significantly.

Today, news about dementia appears in every newspaper, magazine, and television newscast. Thousands of older people alive today will suffer from dementing illness. Most will have emotional and behavioral problems as a result. Currently, very few mental health professionals are knowledgeable about the symptoms, deficits, and treatment of the dementias.

In the coming years, thousands of older people will need mental health care. As a healthcare professional, you cannot ignore the impact of this demographic change. As your patients and clients age, they will face new challenges. Few get psychotherapy, and most get psychotropics from primary care physicians, often without a physical exam.

Geriatric mental healthcare is based on the premise that older adults have unique psychological needs. Many will have multiple medical problems that impact their emotional health and obfuscate accurate diagnoses. The majority will be taking medications that can cause psychological and behavioral problems.

Others will have changes in memory and cognition that require that interventions and treatments take on a different approach. Although most adults live independently in their home, many are living in long-term care facilities. The majority of these people up to 90 percent in this setting will be suffering from mental, emotional, or behavioral problems. The number of people in long-term care facilities is expected to quadruple in the next twenty-five years.

Neither the long-term care industry nor the health care professionals who serve their clients are prepared to meet this challenge. Currently the quality and availability of mental health care leave much to be desired.

Mental health problems are routinely ignored, medicated, or tolerated, but seldom treated effectively. There are a number of reasons for this, one of which is the broad diversity in quality of the facilities. Although many are exemplary in their care and resident-centered focus, others are atrocious. While the best facilities are dedicated to maximizing the quality of life of their residents, the worst facilities focus on the quest to maximize profits and avoid litigation.

It is this stance that has given the news media an abundance of horror stories, and the industry a bad reputation. We are the only industry where many people would rather be dead than use our services. In order for this attitude to change, there must be a fundamental reworking of the delivery of services, and this includes the establishment of high quality mental health care — delivered by you. The long-term care industry is still struggling to define itself.

Long-term care services are provided by a range of different entities — including volunteer organizations, government-funded facilities, and private companies. Three million Americans resided in nursing homes during Currently there are about 17, nursing homes in the United States. About three quarters of long-term care facilities are privately owned, for profit businesses, marketing various levels of care to the infirm elderly.

Nonprofit institutions currently provide care for about 28 percent of institutionalized elders, while another 6 percent reside in government-funded facilities. As of , over 14 million people were living in long-term care facilities. Ninety percent of nursing home residents are 65 and above, and 7 in 10 residents are women.

Over half of women and about one-third of men over 65 will spend some time in a nursing home. Long-term care is a range of services and supports one may need to meet personal care needs. Most long-term care is not medical care, but rather assistance with the basic personal tasks of everyday life, sometimes called Activities of Daily Living ADLs , such as:. Nursing homes came into being to treat people who were recovering from a serious illness or injury.

Once they recovered, they went home. But today the majority of people living in long-term care facilities will spend the rest of their lives there. Of the people who are admitted to long-term care, only 20 percent will return to their previous homes.

The long-term care facility will be their permanent dwelling place — their new homes. This is important because a home should be a sanctuary, a place to feel safe, and a source of nurturance. Despite this, many long-term care facilities bear a closer resemblance to a hospital than a home.

Most people — including mental health professionals — have never set foot in a long-term care facility; this is largely because people avoid them.

As of this writing, I have yet to meet a licensed mental health professional whose primary career goal was to work in a nursing home. While many community-dwelling elderly people have the same degree of physical disability as those in nursing homes, the decision for placement in a care facility is usually related to the amount of family and social support, and the presence of a mental disorder.

Currently in many states, long-term care facilities house the bulk of the elderly mentally ill. Since the deconstruction of the state mental health systems, these people have nowhere to go, and end up in long-term care. The problem is that many long-term care facilities do not see themselves as mental hospitals , and are not set up to deal with the challenges their residents present. Oftentimes staffs have little or no training in mental health care, and because they are so overwhelmed with the tasks they are given, pay scant attention to the emotional state of the people for which they provide care.

Mental health has always been the bastard child of medicine, but here it is truly an orphan. It is time we changed that, and this is where you fit in. Mental health problems are rampant in the impaired elderly population. In December of , the reported incidence of mental health problems in long-term care residents was:.

Older adults suffer from the same psychological problems as younger adults. While the proportion of mental health problems is approximately the same for younger adults, older adults are more vulnerable than younger adults to develop psychological problems resulting from factors that impact the quality of life such as stress, ill health, loss, decline in cognitive skills, and changes in living situations.

Although aging affects everyone, its rate and extent varies from person to person. Changes in childhood and adolescence are stepwise and predictable, but advancing age means increased diversity. In the latter decades of life, people age at very different rates. For this reason, there is no such thing as a "typical seventy-year-old. With age, cells become less able to divide and reproduce. Over time, cells lose their ability to function, or they function abnormally.

There is an accumulation of pigments and fats inside the cells. Cell membranes change, impairing the ability of tissues to get oxygen and nutrients, and to rid the body of carbon dioxide and waste products. Heart, blood vessels, and capillary walls thicken slightly. Connective tissue becomes increasingly stiff, which makes organs, blood vessels, and airways less flexible. Green tea may lower lipofuscin and lower oxidative stress in the brain. Aging organs gradually lose function.

Up to a point, this loss goes unnoticed, because people seldom use organs at full capability. This means that in day-to-day life, a person may function normally, but when placed under stress, demands on the system exceed capacity. When demand exceeds capacity, organ failure occurs. Loss of reserve also makes it harder for the body to maintain homeostasis and restore equilibrium. This means prolonged reactions to stress and longer recovery times from illness.


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You are traveling through another dimension, a dimension not only of sight and sound but of mind. Your next stop, the Twilight Zone! You unlock this door with the key of imagination. Beyond it is another dimension—a dimension of sound, a dimension of sight, a dimension of mind.

You're moving into a land of both shadow and substance, of things and ideas. You've just crossed over into the Twilight Zone. Wikipedia has an article about: The Twilight Zone TV series. Wikimedia Commons has media related to: Retrieved from " https: Views Read Edit View history. In other projects Wikipedia. This page was last edited on 28 August , at This means reduced capacity to detoxify the body and eliminate waste.

This can affect medication dosages also, and toxic buildups are common in this population. About 20 percent of women and 8 percent of men over 65 will experience urinary incontinence. This has a great impact on their sense of control, and also leads to anxiety, embarrassment, and social isolation.

The most significant changes occur in the heart and lungs. With age, the heart loses elasticity, which reduces capacity. Thickening of the aorta decreases delivery of blood to the muscles. Lungs lose function also. The average year-old today has about 40 percent of the aerobic capacity he had at Fortunately, these changes can be minimized by an exercise program. Studies show that brain cells begin to die at an early age. Brain weight actually peaks at years and steadily declines thereafter.

In healthy people, the brain loses 5 to 10 percent of its weight between the ages of 20 and Researchers say age-related changes in the brain in four distinct periods of life. About 20 to 30 percent of central nervous system cells are lost from age 25 to For some unknown reason, this cell loss is greater in men than it is in women of the same age. After age 40, the hippocampus — the part of the brain that allows us to store new memories — loses about 5 percent of its cells every ten years.

As a result of this cell loss, the average healthy eighty-year-old has about two-thirds of the hippocampal cells that he had when he was born. Although cell loss is significant, there are fortunately, so many cells in these brain areas that the normal loss of cells does not significantly impair brain function.

The greatest loss of neurons occurs in the superior temporal gyrus, a part of the brain that moderates hearing, taste, and smell, and in the anterior central gyrus, which controls movement. The smallest amount of loss occurs is in the posterior central gyrus, which controls peripheral sensation. As nerve cells are lost, glial cells cells that support and nourish brain cells increase in number, size, water content, and weight.

Ventricles the hollow chambers in the brain that contain spinal fluid , increase in size. Myelin the insulation around the brain cells thins. Inter- and intracellular deposits of lipofuscin and heavy metals such as aluminum, cadmium, and iron increase.

Microtubules the scaffolding that supports the cell decrease in number, and the neurofibrillary tangles symptomatic of Alzheimer's, composed of deformed microtubules, proliferate.

Neurotransmitters decrease up to 50 percent in some areas. This occurs especially in the substantianigra and basal ganglia areas where dopamine is found often resulting in Parkinsonian-like symptoms. Dopamine also regulates pleasure and reward, and its loss can cause apathy and disinterest — common symptoms in the elderly, very often mistaken for depression.

The vascular system is the most potent predictor of brain health. Many have high blood pressure, but often have no symptoms. Researchers are now saying that high blood pressure at sleep-time is an independent predictor of cardiovascular and cerebrovascular disease. They also have found that people who sleep five hours or less a night are more prone to higher risk of developing high blood pressure.

Therefore asking about sleep should be useful. Men with erectile dysfunction often have concurrent vascular problems. The brain undergoes multiple changes with age. High blood pressure can cause damage to the brain.

Because of this, there is a 20 percent decrease in blood flow from 30 to 70 years of age. As vessels thicken, they impair the transport of nutrients and oxygen. In any part of the brain, thickening and stiffening of the arteries and arterioles will result in disturbances of blood supply, resulting in impaired brain function. The most common causes of this are hypertension, diabetes, cigarette smoking, and hyperlipidemia elevated levels of fats in the bloodstream that include cholesterol and triglycerides.

Blockage of cerebral arteries by plaques or from emboli floating bits of fat and cholesterol in the bloodstream can also block blood flow and cause small strokes often called infarcts. The most common causes of this are atherosclerosis and cardiac arrhythmias, both found in many older people.

Unfortunately many older adults were long-term smokers, and therefore will be suffering from both vascular and lung problems, both of which impair brain function. Recent research done in Europe by Alewijn Ott involving more than 9, elderly people noted that older smokers lose cognitive abilities five times faster than nonsmokers do.

Furthermore, the more a person smoked, the higher the rate of decline they experienced. Although impaired blood flow is damaging to all parts of the brain, the most vulnerable areas are the basal ganglia and subcortical white matter. In contrast to the cortex, which has a double vascular supply, the subcortical white matter and basal ganglia have but a single, minimally-branching supply. Therefore, any damage in this blood supply means that the basal ganglia or white matter will become ischemic, and cells will experience demyelination, and die.

These are parts of the brain responsible for movement, coordination, and volition. Be aware that many older adults are taking statin drugs cholesterol-lowering drugs. These drugs are known to cause mood disorders and significant cognitive problems.

In the elderly, lowering cholesterol is related to all-cause mortality elder adults, even when adjusted for other health status or indicators of frailty. Statins are also associated with an increased risk of rheumatoid arthritis, which can cause agitation and depression. Personality appears to remain relatively stable throughout the lifespan, but age often changes behavior, cognition, and emotion. They found evidence that personality does change during adulthood.

Another study by Field and Millsap reported that neuroticism decreased until age 69 and remained stable until age 83, while agreeableness increased and extroversion declined until age Elders who score high in neuroticism and low in extroversion have poorer perceived health, and are more likely to suffer from anxiety and depression as result. In , Bernice Neugarten, et al. However, there was a shift from what they labeled Active Mastery e.

With advancing age, subjects reported a greater preoccupation with inner feelings, experiences, and cognitive processes, and avoidance of external influences on belief structures i. Researchers Mroczek and Almeida at Fordham University found that aging resulted in a stronger association between daily stress and negative feelings.

The higher a person scored in the trait of neuroticism, the stronger the reaction the person experienced. They concluded that there was a heightened reactivity to stressors in older adulthood, perhaps due to kindling effects, most likely caused by changes in the aging brain see above. While the evidence suggests that personality traits are relatively stable, so are personality disorders. This means that older people retain their maladaptive traits as well as their healthy traits.

The presence of a personality disorder is a common reason for referral to a long-term care facility. For this reason, many people in long-term care may be volatile, difficult people who are also struggling with medical problems and cognitive changes. This presents a challenge for staff and administrators, many of whom know nothing about personality disorders and therefore may actually exacerbate problems.

There is a great need for mental health professionals to provide intervention and education in this treatment setting. Researchers say that a patient-centered paradigm is the best way to help the elderly. Such a paradigm means getting to know the person and understanding his or her needs, also doing a complete workup looking at needs, pain, fear, and loneliness.

About fifty million Americans provide care to an older relative or friend. Caregiver and family therapy is probably the most overlooked resource for the older population. At the time of this writing, we are just beginning to acknowledge the immense need for this type of intervention in dealing with family stress, caregiver burnout, and dealing with very complicated family constellations.

Because of the increase in lifespan, the average adult today will experience triple the amount of years spent with living parents than in This means more support from parents, but also more responsibility in caring for them.

Many elders will eventually come to live with their children. The most common cause of family discord is when a parent becomes too ill to live independently and begins to depend on children for assistance. According to researcher Victor G. Cicirelli at Purdue University, this causes filial anxiety — the anticipation of significant responsibilities often causes friction and conflict between the parent and child.

As parents lose the role of power, retaliation and resentment often arise. Old wounds are revisited and old issues reappear. Friction between siblings is ignited. Old family rivalries and power struggles are reinstated. Adult children of the elderly often become conflicted between control and responsibility.

Children argue over who will accept responsibility for the ailing parent. Once the decision is made, the chosen sibling may get constant criticism about the way she is handling things. Eventually most adult children of elders achieve filial maturity , that is, they have accepted the responsibility of being depended upon by their parents, but in families where the parent-child relationships have been stormy, trouble will brew.

Loss of power in which a resented parent reanimates old wounds is a frequent cause of elder abuse. After rivalries and conflicts have been resolved and caregiving commences, caregiver burnout often occurs. When a caregiver becomes emotionally and physically drained due to the caregiving role, irritability, fatigue, and depression set in. At this point, many caregivers become ambivalent about their role.

This may manifest itself as argumentativeness and belligerence, followed by bouts of guilt. Families often become destabilized and volatile without being consciously aware of the source of their discord. Because of extended life spans and the need for companionship, many elderly people remarry, while others cohabit because of the financial consequences of marriage. As a result, family constellations become very complex; with multiple marriages come new children, nieces and nephews, stepchildren, and many sets of grandchildren.

Boundaries and loyalties are fuzzy and confused, and many conflicts arise. While working with younger people may not involve family sessions, interactions with family members are an important part of every care plan in this population. At best, the family can be a valuable resource. They can provide historical information and furnish data on what types of care giving have been most successful in the past. They also provide a powerful source of comfort and support for the resident.

But at other times, families may present problems. In many cases, the family members have become accustomed to being the primary caregivers, and are over-involved with the patient. Although they mean well, they may disagree with caregiving, and sometimes actually interfere with treatment. According to researchers J. Paul Teusnik and Susan Mahler, families of elderly patients with progressive cognitive decline undergo a step-wise process in attempting to cope with the disorder.

Teusnik and Mahler feel that families coping with debilitating disease exhibit similar reactions to families coping with death. Because of this, caregivers should provide the families with information and education about this process so that they can see that what they are feeling is normal. With support and guidance, a family can successfully work through its reactions and be able to mourn the loss of their loved one, make the necessary decisions for her care, and reestablish a new family equilibrium.

In spite of the evidence, they insist that there is nothing wrong with their loved one. This reaction is sometimes the result of the family's lack of education about aging, but it is also a wish on the part of family members to deny what they are seeing.

Denial is a way of defending against the pain of loss. In these cases, denial makes any objective assessment, decision-making, and treatment-planning difficult. Families who exhibit excessive denial must be helped through education and, at times, through outright confrontation in order to recognize the extent of the disability of the family member. Although this may lead to further anger, it is only when denial is overcome that the family will be able to make sound decisions and realistic plans for treatment.

Denial is often followed by intense over-involvement of family members with the patient in an attempt to deal with the illness. As the deterioration of the afflicted family member becomes more obvious, family members may take over daily tasks and responsibilities in an effort to compensate for the deficits.

At this point, a role reversal takes place. Frequently the family member must almost become a parent to his or her own parent. This can be one of the most difficult adjustments that a family member must face. In addition, he often must assume the patient's former family role, which may include taking over legal and financial responsibilities. This task can be difficult and stressful. Occasionally, family fights break out about who is to take on this responsibility.

Tasks and responsibilities that were done by one spouse for many decades are sometimes incomprehensible to the non-ailing partner. For example, some wives have never written a check or paid a bill, and, in combination with the stress of dealing with illness in their spouse, find the task overwhelming.

When involvement with a parent becomes an obsession, family members sacrifice their personal lives and become consumed with the caregiving task. Even when they recognize that they are in over their heads, they may be reluctant to seek professional help, thinking that to do so is to betray their parent. In fact, some families raise sons or daughters to believe that they must care for their parents regardless of how disruptive it may be to their own lives.

The children feel that to not do so will result in ostracism and ridicule by their family, and their community. This belief often stretches them to the breaking point.

In these cases, the person must be helped to understand what is within his power to do, and what is beyond his limits. Professional caregivers should be able to recognize the difference between a normal reaction and over-involvement within the family and its culture. Families must be helped to see that their over-involvement is actually a hindrance rather than a help in providing top-quality caregiving. When doing this, family members should be provided with solid evidence of what problems the over-involvement is causing for the patient, the staff, and for the rest of the family.

Eventually, over-involved family members react in anger, feeling unable to shoulder the tremendous burden of caring for their loved one. Anger among family members develops for many reasons. In addition to the burden of caring for a disabled spouse or parent, they cannot tolerate the bizarre and socially inappropriate behavior the loved one is exhibiting.

Anger also can erupt from the feeling of having been abandoned by a still-living, but now helpless, parent or spouse. Regardless of its source, this anger is often projected or displaced onto the very people who are trying to help the family deal with their overwhelming sense of helplessness — the caregiving professionals.

Mental health professionals must be able to recognize this, and help the family confront and deal with its anger. When families fail to see that they are projecting their own painful feelings on caregivers, they often accuse staff of neglecting the patient and causing the deterioration that, in reality, naturally occurs with this illness.

Since the normal reaction to being accused of neglect is defensiveness or anger, either of which will further alienate the families, caregivers must be able to handle this anger effectively. As anger lessens, guilt may become more obvious.

Feelings of guilt can be a normal reaction to recognizing the feelings of anger. Guilt may also come from unexpressed-as-unacceptable wishes that the suffering loved one die.

Family members may feel guilty for believing they waited too long before seeking professional help — and by doing so contributed to the suffering. Guilt can also come from the need to make medical and financial decisions that are objected to by the elderly person. Guilt may also be the reawakening of old feelings — feelings that they were not attentive enough to their parent or spouse in earlier times — or for abrasive and cruel comments from times passed.

Family members often mix their guilt with a dash of failure. They have tried their best to care for their loved one, but the task was more than they could bear. It is vital to keep this in mind when dealing with family members. You cannot truly understand their pain until you have walked in their shoes. In these cases, support groups can be a great resource for families that have been struggling with an ailing elder. Unfortunately, this guilt sometimes becomes translated into a need to dictate orders to the staff and caregivers.

They confuse interference with involvement. One such case involved Jim Stevens and his father. Jim Stevens brought his father to the nursing home because caring for his dad was disrupting his job to the degree that he was at risk of being fired.

He told the administrator that he wanted to be notified of any and every problem his father was experiencing. He made it clear that no treatment of any kind was to be administered to his father without his approval. Stevens was very difficult to reach. He seldom returned phone calls, and sometimes could not be reached at all. This resulted in impeding any semblance of quality care. The administrator invited Mr. Stevens, I know you care for your father a great deal. I know you worry about him.

And we are all impressed with your concern and your involvement. If we have to wait, your father may suffer unnecessarily. One component of this can be simply to educate the family about the illness itself, thereby providing reassurance that the family has not harmed the patient.

More extensive counseling may be needed to help the family make difficult but necessary decisions, some of which may be objected to by the patient. Acceptance comes only when a family is able to truly understand the disease or disability that is affecting the loved one.

Once the family members have worked through the bulk of their anger and guilt, and have recognized that their loved one is no longer the person they once knew, they can accept the loss.

In cases of dementia, acceptance can be especially difficult. This disease's insidious onset and long, slow progress give one false hope that things will remain as they are. In addition, the patient's relatively normal appearance during the early stages of the illness makes the problems seem less serious than they really are.

K, a profoundly demented year-old Jewish widow, was transferred from a long-term care facility to the Cornell Medical Center for an evaluation of agitated behavior including constant pacing, verbal abusiveness, and at times, combativeness. K had exhibited symptoms of Alzheimer's disease for approximately one and a half years, she had worked in her family's garment manufacturing business until one year before her transfer to the Center. In the transfer summary, the nursing home complained of difficulty with the patient's year-old son, who was running his mother's business.

During the initial phase of his mother's hospitalization in our facility, Mr. K was unable to accept his mother's progressive deterioration and was insistent that certain signs, such as intact long-term memory, were proof that she was less impaired than he had been told. He believed that his mother's wandering stemmed from her boredom at not having work to do and from the lack of staff engaging her in activity. K visited his mother nightly and brought her dress patterns to cut. When she was unable to perform the tasks he expected of her, he displaced his disappointment and anger onto the nursing staff in a hostile, abusive, and accusatory fashion, thus engendering staff defensiveness and resistance to empathizing with his pain.

K was critical of all aspects of his mother's treatment and expected the hospital to find a miracle cure for her illness.

K in family therapy was difficult since he saw both the doctor and social worker as his adversaries. He was seen in weekly sessions, where he was encouraged to talk about his frustration at our inability to make his mother well. At the same time, we educated him about Alzheimer's disease — its manifestations, course, and treatment. K eventually revealed his concerns that the illness was hereditary or contagious, and his feelings of helplessness in caring for his mother.

He had attempted to have her live with his family before placing her in a nursing home, but he and the family were unable to control her wandering and disruption of family life. K began to discuss his family history and his feelings about his mother, it became clear that he had a conflict-ridden, ambivalent relationship with her. K had worked long hours in the family's business since Mr. K was a young child and had left his care to an older sibling. K had felt neglected and abandoned, and had developed angry feelings toward his mother.

Having to put his mother into a nursing home reawakened these repressed feelings of anger and abandonment, and aroused concerns that he was now abandoning her. He was still unable to see his mother as anything other than the strong, capable, working woman he had known in the past, and although he was capable of running the family business, he was experiencing self-doubts.

In addition, he was furious at his sibling, who lived out-of-town and was not involved with his mother's care. K's reminiscences about his mother helped him to realize the source of his angry feelings and he became less critical of the staff. His lessened anger enabled him to understand the symptoms of Alzheimer's disease, to more realistically assess his mother's illness, and to mourn her loss.

K was discharged from our facility, we talked with the social worker in the long-term care facility where Mrs. K would return, so that we could apprise her of Mr.

K's conflicts and encourage her to provide him with continued support. In these cases, unresolved feelings of anger, frustration, helplessness, grief, and fear interfere with healthy family interaction. Once again, family therapy and family support groups can be very useful. Unfortunately, in some cases, the family members have been not only neglectful, but also abusive.

In a survey done in , researchers Pfiffer and Finklehor discovered that between 3 and 4 percent of elders experienced abuse by family members. They also discovered that only one in fourteen cases was ever reported.

Social support plays an important part in the potential for abuse. Elderly people who are isolated from all but their caregivers are four times as likely to suffer abuse as those who have social support. Men are more likely to be abused than women because elderly men seldom live alone. Regardless of who they are, how they act, and what they have done, family members must always be treated with respect, deference, and consideration.

Like the residents, families must be considered to be customers. One frequent problem that long-term care residents have is loneliness. Unfortunately, family visits can be a source of trouble. Negative interactions with family can irritate and agitate patients. For this reason, therapists should encourage families to keep the climate of the visit positive. Explain to them that fighting and friction during a visit can cause behavioral problems for several days.

Family visits can also be an opportunity for residents to complain about the facility and the quality of care. Although some of these complaints may be valid, in many cases the person complains of poor care either because they cannot remember many of the things that are done for them, or because they get pleasure out of stirring up trouble.

During these visits, Mrs. Whitkin would complain incessantly about not being fed, not being cared for, and being generally neglected. We suggested to her daughter that she come to the facility unannounced at different times during the day and stand where her mother could not see her, so that she could observe the things we did for her mother. In this way, she was able to see that we were in fact doing the things that Mrs.

Whitkin claimed we did not do. The daughter then realized that much of what we were doing was simply forgotten. Because families play such an important role in the mental and physical health of their older loved ones they are an important part of treatment.

Get to know them, and learn about their expectations, attitudes, and concerns. They are not only a source of historical information, but also are emotionally involved and impact the life of the person being treated.

Involve the family in the care plan whenever possible. Even minimal participation gives them a feeling of power and participation, and increases treatment compliance a great deal. Listen to, acknowledge, and validate the feelings and concerns family members are having. If they are not forthcoming with these feelings, offer information on what kind of feelings are typical and ask them if they are experiencing any of them. It would not be unusual for you to be feeling any or all of these things.

Family members sometimes express their concern and anxiety as anger. Instead, validate their anger and offer solutions. Be responsive, not reactive. Carefully explain the symptoms and problems that the resident is experiencing. Explaining problems and unusual behaviors helps the family understand and cope with what they are seeing. These devices allow the patient to talk to and see their friends and families. Most of these devices have audio and video recording of the visits are very useful.

While it is not as gratifying as a real visit, most people enjoy them again and again. These devises can also be used for music, movies, books, and magazines.

As mentioned above, adult children tend to minimize the impairments and disabilities of their parents and overestimate their ability to care for them. Eventually, caregiver burnout takes its toll, and with it comes the realization that a higher level of care is needed. Although most families make heroic efforts to care for their ailing elderly, many eventually are forced to consider moving the person into a professional care facility.

The decision to admit a parent, a spouse, or any family member to a health care facility is difficult and painful. It is usually made when all other alternatives have been exhausted. It is seldom made without guilt, remorse, hurt, and anger. The move from home to a retirement home, assisted living, board and care, or skilled nursing facility is a very difficult transition for both resident and family.

To family members, it means the loss of much of what has become familiar. They must adjust to living without the loved one. They must grapple with the reality that they are not equipped to give adequate care.

They must lick their wounds and learn their limitations. To the person entering the professional care facility, it means dealing with multiple losses. She loses her home, her privacy, and her independence. Friends, treasured objects, lifestyle, and much of what she knew are gone forever. This overwhelming sense of multiple losses is usually accompanied by anxiety, depression, and disorientation. Although leaving home and entering a care facility is traumatic, relocation from one facility to another also takes its toll on the physical and psychological health of elders.

In fact, older people face an elevated mortality risk whenever they are relocated. Studies of the effect of transferring people show that there is an elevated mortality risk — between 1. In , after years of observing and documenting this problem, health care experts officially named this phenomenon Relocation Stress Syndrome.

The United States Administration on Aging calls this problem Transfer Trauma, and notes that relocation is associated with depression, increased irritability, serious illness, and elevated mortality risk. After a move, the fear and grief that the person experiences are often expressed as anger and agitation.

While fear disables a person, anger is empowering. To a person who has lost most of her personal power and position, anger and resistance may be the only way to feel her impact on the world.

Understanding the origin of this fear, anger, and resistance allows caregivers to reach beyond the anger and gently touch the pain. A kind word and an understanding attitude can make this difficult transition much more bearable.

The stress of moving to a care facility was carefully examined by Coffman in In other words, it was not the change itself but the emotions that surrounded that change that made the event difficult. With age, social circles decline. Most institutionalized aged people have no spouse, no close relatives, and the majority of them have no visitors. A new term — elder orphans — has been coined to fit this population.

Up to 60 percent of people in long-term care have no family. Because of this, they may have no contact with the outside world. This type of social isolation results in rapid deterioration of physical and mental health.

Another social dynamic that is often overlooked is the impact of cultural differences. For intervention and treatment to be effective, the practitioner must take into account the norms, values, lifestyles, diets, and diseases of various ethnic groups and the impact that they can have on elderly people. Although much work has been done in the field of cross-cultural psychology, little has been done in elderly ethnic populations.

Cultural differences affect willingness to seek treatment, compliance with treatment, and the ways that families treat their elder members. For instance, researchers find that African Americans, Native Americans, and Hispanics place a great deal of importance on self-sufficiency, pride, and independence. Probably the biggest difference between treating emotional and behavioral problems in younger people and in the elderly is that most elderly people are also suffering from multiple medical problems.

Psychological problems in this population are often indicators of physical illness. In fact, more than half of all older psychiatric patients have an undetected physical illness. Older people who have a previous history of mental illness are more likely to suffer from mental problems in later life.

Barring that, medical illness is the strongest predictor of mental illness in the elderly. High medical users are more likely to suffer from depression, anxiety, and adjustment disorders. Medical illness also predicts cognitive decline. In a study by Backman, et al. A troubling finding in geriatric mental health assessment is that almost 80 percent of physical illnesses are missed by psychiatrists during the initial assessment.

This happens in part because mental health practitioners are trained to look at symptoms as signs of psychopathology, not medical illness. The other reason for this oversight is that only about 10 percent of psychiatrists specialize in geriatrics. The three top unrecognized conditions are constipation, urinary infection, and hypothyroidism.

The reality is that medical problems can cause serious behavioral and emotional disorders, and these factors should always be considered before any diagnosis or behavioral intervention is attempted. Medical disorders may also present themselves as confusion or functional decline.

These things may be mistaken for normal aging, while they are, in fact, masking a serious problem. It is important to be aware that while there are many people who have medical causes for mental illness, almost everyone has strong emotional responses to physical illness.

Disease burden significantly increases levels of stress, anxiety, and depression. For example, people undergoing dialysis face multiple challenges.

First, they must cope with the loss of function of their kidneys. This is a devastating loss, which is often accompanied by a great deal of anxiety, depression, and grieving.

Second, dialysis means adopting an entirely new lifestyle — one in which several days a week are devoted to treatment. Third, a majority of people in dialysis feel exhausted after the procedure, and cannot do anything strenuous the rest of the day. Fourth, they must accept strict dietary restrictions to maintain their health.

Dialysis patients also have a high incidence of sleep apnea, which causes cognitive problems and exacerbates fatigue. Dialysis patients are at risk for thiamine deficiency, which may mimic symptoms of dementia. In rare cases, dialysis can result in a toxic buildup of aluminum in the brain, which results in dementia-like symptoms sometimes called dialysis dementia.

This occurs over time in areas where the water supply contains high levels of aluminum. Although this is a fairly well known phenomenon, it is often overlooked or missed. Untreated, it is often fatal. The incidence of depression is very high among dialysis patients, and a depression screening should be routine in this population.

About one in ten people undergoing dialysis choose to end their lives by discontinuing treatment. Elderly people often undergo surgery, and although most of these surgeries go well, it is not uncommon to see drastic behavioral changes after their return from the hospital. The trauma of surgery itself always causes a significant amount of stress. The most common problems associated with surgery are:.

About 30 percent of older adults will experience irreversible problems with memory and cognition after a major surgery. Problems with memory and thinking after surgery occur because of several factors.

Caloric demand, the amount of energy consumed by the body, often increases as the body tries to heal itself. Sometimes tiny clots are thrown during and after the surgery, which may result in minor strokes and, consequently, impaired brain function.

Older people may also fail to metabolize the anesthetic properly. In addition, being anesthetized for hours may causes anoxia oxygen starvation which can lead to diffuse brain damage, causing memory and behavioral problems. Unfortunately, many elderly residents undergo the loss of a body part, limb, or the loss of the function of a limb.

Losing a limb is a traumatic and devastating experience. They no longer feel normal; often, they do not feel accepted. These feelings are made worse by the reactions that others have to the injury. Many people find amputations frightening, and avoid looking at a person with a missing limb. In their efforts to cope with their fear of rejection, the person may become withdrawn or lash out at others, feeling that by rejecting others, they can save themselves from being rejected.

During this time, the person may be difficult to work with — they may be uncooperative, unpleasant, and abusive. It is important to keep this in mind when working with a person who has lost a limb. It is normal for a person to go through a period of grieving for their missing limb, yet they are often reluctant to discuss their feelings with others. Addressing the issue head-on is often the best way to open the avenue to communication.

She told me it was a very difficult time for her. I wonder if you might be feeling that way, too. Other problems accompany amputations. Blood pressure may be altered. Balance and gait may be affected, and phantom-limb pain may cause discomfort and anxiety. About one-third of women have phantom breast sensations after a mastectomy. There is research describing successful treatment with acupuncture for phantom-limb pain.

At Eastern Cognitive Disorders Clinic, cognitive neurologist Amy Brodtmann has found that each year around fifteen million people worldwide have a stroke. Of these, at least five million die, a third remain disabled, and the remainder make a good recovery. Yet depression is a common consequence of stroke. It is particularly true if the stroke has resulted in permanent disability.

The patient often loses much of his independence, and often suffers from body image difficulties previously discussed. If the person has lost the ability to speak, things are even worse. Loss of the ability to communicate is a devastating loss, and often results in complete withdrawal.

When people are able to use this device their world changes. Several years ago, I was called in to see year-old women named Madeline.

She had recently become confused, disoriented, and was beginning to show some signs of dementia. In the course of the interview, it was discovered that she was drinking very few fluids. When fluids were increased, the symptoms went away within three days.

A great many elderly people do not drink enough water. In some cases, this is because they have lost their sense of thirst. And they are right. The decreased fluid intake reduces their need to urinate.

Incontinence is often a source of shame and inconvenience, and not drinking reduces the problem. Unfortunately, it also causes fluid and electrolyte imbalance in the brain, and can cause dementia-like symptoms. Very often, correcting incontinence problems eliminates dehydration, and thus eliminates behavioral problems.

Being knocked unconscious can cause a closed head injury. About one third of all injury-related deaths in the USA are associated with a traumatic brain injury. This condition is caused by the bruising or tearing of delicate brain tissue. The brain is a jelly-like substance that is suspended in a bath of spinal fluid. It is protected by rubbery membranes called the meninges.

Minor bumps on the head do not usually cause any damage. A concussion is a temporary loss of consciousness occurring after a blow to the head. The impact of the blow causes the semi-liquid brain tissue to slosh about inside the skull, causing it to bruise. Like any bruise, the injured tissue then swells. When the brain becomes bruised and swollen, brain function can be disrupted for weeks after the injury. This can cause loss of memory, and sometimes results in permanent brain damage.

In younger people, most concussions are caused by traffic accidents, but in the elderly they can also occur from falls, or from being hit on the head by any object.

Immediately after a concussion, the victim may experience confusion, memory loss, vomiting, and blurred vision. The longer the person is unconscious, the more severe the symptoms tend to be. About one-third of the people who experience a concussion will exhibit post concussion syndrome. This condition includes chronic memory loss, dizziness, and changes in behavior that can last over a year.

Because most knocks on the head are soon forgotten, the person usually does not connect the symptoms with the accident. Repeated concussions, such as those experienced by boxers, can cause permanent brain damage, including a condition called punch-drunk syndrome. One study revealed that 87 percent of former boxers showed evidence of brain damage.

We also know that a significant number of those suffering from dementia have a history of head injury. Elderly people often bump their heads and later forget that the incidents happened. In a younger person, these bumps may be unimportant, but the brains of elderly people are sometimes smaller, and slosh about inside the skull more easily. The decreased amount of neurons in the elderly brain makes minor damage more serious. Even small bumps on the head in the elderly, such as a knock on the head from a cabinet door, can cause subdural hematoma bleeding inside the lining of the brain.

Any bump on the head should be checked thoroughly. As soon as possible after a person has experienced a loss of consciousness, she should see a doctor to rule out skull fracture, brain injury, or subdural hematoma. Subdural bleeding is a serious condition that requires immediate medical attention. Weeks after a head injury, the person may experience headaches, dizziness, changes in behavior, drowsiness, and memory loss. A common concern for people over 60 is falling.

A great many people who complain of dizziness are suffering from Parkinsonian difficulties; that is, if they lose their balance, they cannot regain it, and they may fall.

Others use the word dizzy to describe muscle weakness or damage that results in unsteadiness, and causes the person to fall or bump into things. Some people are actually experiencing the results of orthostatic hypotension, a sudden drop in blood pressure upon standing. This means that when they stand up too quickly, they feel faint. This drop in blood pressure can be caused by medications or chronic low blood volume. Low blood pressure can also be a sign of internal blood loss, which is a serious condition.

Still others are dizzy because of vestibular disorders — malfunctions in the balance apparatus in the ear that result in a feeling that the room is spinning around. Also known as vertigo , this can cause nausea and panic attacks. This can be caused by ear infections or damage to the balance organs themselves. Thirst is the sensation caused by dehydration. The third part of the brain, the brainstem, connects the brain to the spinal cord which controls hunger and thirst.

The sense of thirst is mediated by sensors called baroreceptors. They are located in the aortic arch and carotid sinus, and are stimulated by reduced fluid intake. The continuing loss of fluid through the skin and lungs and in the urine and feces requires that fluids need to be replenished throughout the day.

As people age, baroreceptors decrease, and the sense of thirst becomes impaired. When older adults aged 65 to 74 and young adults aged 21 to 30 were given salty water to make them thirsty, the elders drank half as much water as the younger subjects.

Older people are often reluctant to drink water because of incontinence. High water content foods like popsicles and gelatin improves hydration. Psychotherapy is very useful in improving the quality of life of older adults. However, the most overlooked and undervalued causes of behavioral and emotional problems are inadequate or poorly balanced nutrition and the nutritional deficits that come with aging. Therefore, a nutrition assessment should be done before any intervention.

As people age, they often have deficits in their senses of vision, smell, and taste, decreasing their enjoyment of food. Elderly people also have a tendency to narrow the scope of what they will eat, and therefore may become deficient in certain vitamins and minerals. Often, because of financial difficulties, they consume less protein and increase the consumption of refined carbohydrates, which can destabilize blood sugar. Volatility of blood sugar significantly increases the risk of dementia.

In some long-term care environments, meals leave something to be desired. Not only is food of poor quality, but dietary preferences are usually ignored. In one facility where I worked, 70 percent of the residents were Hispanic, but despite their complaints, no ethnic food was offered.

Being forced to eat food the person does not enjoy, and having no choice in what a person eats, results in non-compliant eating and inadequate nutrition. Older people may also lose their sense of hunger.

Hunger is physiological but appetite is psychological. It has been found that the biochemical imbalances that cause anorexia in younger people and changes in the natural aging of the brain are very similar.

Drug withdrawal and depression may also cause geriatric anorexia. The consequence of brain changes combined with unhappiness with menu choices often leads to inadequate intake of calories and essential nutrients and a condition known as failure to thrive. Jan Berend Deijen has observed that the level of daily functioning in geriatric nursing home patients is related to both adequate nutrient intake and body weight. Studies show that about 15 percent of older people require professional intervention for failure to thrive.

This condition includes a decline in physical health, weight loss, loss of appetite, and social withdrawal in the absence of any obvious cause. Along with the physical decline, there is often depression, anxiety, and confusion. Making food more attractive does not have to be expensive.

Just doing this increased caloric intake by 25 percent. In another study, adding natural flavoring to meals increased intake and enjoyment of meals significantly. More flavor and aroma compensated for taste and smell deficits that accrue with age. Sadly, failure to thrive may also be the result of neglect.

I have worked with families that literally starved their partners to death. R arrived in the emergency room with a questionable new stroke. He was dehydrated and had lost 50 pounds. He was unable to walk and was incontinent of urine and stool. During assessment, the patient confided that he felt he was a burden to his wife.

R thought that Mr. R was doing this on purpose. Thus, she would restrict food and fluids to decrease the frequency of the episodes of incontinence. Cases of neglect like this often come to light when a patient improves rapidly in the hospital, and again deteriorates when returned home. Vitamins and minerals are important for health. Vitamins minerals and other nutrients are often given to older adults, but overdose of these chemicals may contribute to polypharmacy. Folic acid and B 12 levels are found to be low in a large proportion of residents suffering from various emotional problems, especially depression and anxiety, but deficits also contribute to symptoms of disorientation, depression dementia, and psychosis.

Although B 12 deficiency is common in the elderly, measuring levels of B 12 in the blood is not always useful. B 12 deficiency may not become apparent until long after serum levels have been greatly reduced, and symptoms have begun.

In order for this vitamin to be metabolized, it must be transported through the small intestine by a chemical called intrinsic factor. Most people over 60 have significantly low levels of this molecule, and therefore cannot absorb dietary B This means that even if they get enough B 12 in their diet, most elders will be deficient.

For this reason, B 12 deficiency should be assumed to exist in the majority of older people. The most effective way to get B 12 into the bodies and brains of the elderly is by injection or by sublingual under the tongue tablets, both of which bypass the gastrointestinal system. This should be a routine intervention in all older patients manifesting psychiatric symptoms; however, in the real world it is seldom done.

Instead, antipsychotics and antianxiety drugs are administered, which often cause more problems than they cure. For example, antipsychotic medication appears to increase the incidence of diabetes in this population, and diabetes accelerates dementia. Also, antianxiety medications are the number two cause of falls in the elderly, which are often lethal. Folate and vitamin B12 can reduce the risk of hip fracture in elderly patients following a stroke.

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