Week 8: Mental Health Disorders And Pain/Comfort Flashcards
Stress and Stressors in Late Life
- The experience of stress is an internal state accompanying threats to self.
- The narrowing range of bio-Psychosocial homeostatic resilience and changing environmental needs as one ages may produce stress overload.
Effects of Stress
- Adults show greater immunological impairments associated with distress or depression
- Any stressors that occur in the lives of older people may actually be experienced as a crisis if the even occurs abruptly, is unanticipated or requires skills or resources the individual does not possess.
What are factors that affect stress?
- Cognitive style
- Coping strategies
- Social resources
- Personal efficacy
- Personality characteristics
- Social relationships and social support are particularly important in stress management/coping.
- Resilience
Factors influencing the ability to manage stress
….
General issues in the psychosocial assessment involves
Distinguishing among normal, idiosyncratic and diverse characteristics of aging and pathological conditions.
Mental Health Assessment in Older Adults includes examination for
- Cognitive Function
- Conditions of Anxiety
- Adjustment Reactions
- Depression
- Paranoia
- Substance Abuse
- Suicidal Risk
Mental Health in Older Adults: Interventions
- Enhancing Characteristics of resilience and resourcefulness
- Promote a sense of control, fostering social supports, relationships and connecting to resources.
- Meditation, yoga, exercise, spirituality and religiosity can enhance coping ability.
- Mind-body therapies are most helpful.
- Reminiscence is useful in understanding coping style.
Factors Influencing Mental Health: Attitudes and Beliefs
- Nearly half of people >65 with recognized mental or substance use disorder have unmet needs for services.
- May be looked at as a normal consequences of aging or blamed on dementia.
Why are older adults with recognized mental or substance use disorder have unmet needs for services?
- Reluctance on the part of older people to seek help because of pride of independence.
- Stoic acceptance of difficulty.
- Unawareness of resources
- Lack of geriatric health professionals and services.
- Lack of adequate insurance coverages.
Factors Influencing Mental Health: Culture and Mental Health
- What may be defined as mental illness in one culture may be viewed as normal in another.
- Sexual minority individuals, particularly older gay men, demonstrate higher rates of mental disorders, substance abuse, suicidal ideation and deliberate self-harm than heterosexual populations.
Availability of Mental Health Care
- Dedicated financing for older duly mental health is limited.
- Medicare spends five times more on beneficiaries with severe mental illness and substance abuse disorders than on similar beneficiaries without these disorders.
- Psychiatric services may be provided by a psychiatrist, psychologist, licensed clinical social worker, nurse practitioner, or geropsychiatric clinical nurse specialist.
Factors of Influencing Mental Health: Settings of Care
Older people receive psychiatric services across a wide range of settings, including acute and long-term impatient psychiatric units, primary care and community and institutional settings.
Obstacles to Care in Nursing Homes and Assisted Living Facilities
- Shortage of trained personnel
- Limited availability and access for psychiatric services
- Lack of staff training related to mental health/illness
- Inadequate Medicaid/Medicare reimbursement
Anxiety Disorder
- Unpleasant and unwarranted feelings of apprehension, which may be accompanied by physical symptoms.
- Not considered a part of normal aging process.
Anxiety disorders become problematic when
- Prolonged
- Exaggerated
- Interferes with function
Late life anxiety is often
Comorbid with major depressive disorder, cognitive decline and dementia and substance abuse.
Consequences of Anxiety include
- Decreased physical activity and functional status
- Sleep disturbances
- Increased health services use
- Substance abuse
- Decreased life satisfaction
- Increased mortality
- Increased hospitalizations
Anxiety: Assessment focuses on
- Physical, social, and environmental factors
- Past life history
- Long-standing personality
- Coping
- Recent events
Anxiety: Interventions depend on
- Symptoms
- Specific anxiety diagnosis
- Co-morbid medical conditions
- Current medication regimen
Anxiety Pharmacological Interventions
- First line: SSRIs
- Second line: Short-acting benzodiazepines
Anxiety: Nonpharmacological Interventions
- Cognitive Behavioral Therapy
- Exposure Therapy
- Interpersonal Therapy
Post traumatic Stress Disorder
- A psychobiological mental disorder associated with changes in brain function and structure affecting survivors of combat, terrorist attacks, natural disasters, serious accidents, assault/abuse, sudden and major emotional losses.
- Can include both direct and indirect exposure.
Symptoms of PTSD includes four major symptom clusters for diagnosis:
- Reexperiencing
- Avoidance
- Persistent negative alterations in cognition and mood
- Alterations in arousal and receptivity
Consequences of PTSD
- Depression
- Co-occurring PTSD and depression is associated with greater symptoms, reduced quality of life and increased health care utilization.
- PTSD among Vietnam War veterans more than doubled the likelihood they would develop heart disease.
- There may be an association between PTSD and greater incidence and prevalence of dementia.
PTSD: Assessment
- Identify triggers
- Knowing the person’s past history and life experiences is essential in understanding behavior and implementing appropriate interventions.
PTSD: Interventions
- Can benefit from cognitive behavioral therapy and prolonged exposure therapy.
- Evidenced-based psycho-spiritual interventions.
- Pharmacological therapy.
Types of Schizophrenia
- Early onset (EOS): occurs before age 40
- Midlife onset: occurs between ages 40-60
- Late onset (LOS): after age 60
Late Onset Schizophrenia
More likely to be women, as paranoia is a dominant feature of illness and tens to have hallucinations.
Early Onset Schizophrenia
Individuals with EOS who have grown older may experience fewer hallucinations, delusions and bizarre behavior, as well as inappropriate affect.
Consequences of Schizophrenia
- Life expectancy that is shorter by 20-23 years than that of an unaffected person.
- Incidence of dementia is twice as high.
- Costly disease in terms of suffering and medical costs.
Psychotic Symptoms in Older Adults include
- Paranoid Symptoms
- Delusions
- Hallucinations
Schizophrenia: Assessment
- The assessment dilemma is often one of of determining if paranoia, delusions and hallucinations are the result of medical illness, medications, dementia, psychoses, deprivation or overload because treatment will vary accordingly.
- Treatment must be based on comprehensive assessment.
- Assessment of vision and hearing is also important since these impairments may predispose the older person to paranoia or suspiciousness.
Frightening hallucinations or delusions arise in response to anxiety-provoking situations and are best managed by:
- Reducing situational stress.
- Being available to the person.
- Providing a safe, nonjudgmental environment.
- Attending to fears more than content of delusion or hallucination.
Other Schizophrenia Interventions
- Identify the client’s Strengths and build on them.
- If symptoms interfere with function and safety, consider antipsychotics if other interventions don’t work.
Bipolar Disorder
A recurrent mood disorder that includes periods of mania or mixed episodes of mania and depression.
Bipolar disorder levels out later in life and individuals tend to
Have longer periods of depression.
Bipolar Disorders: Symptoms
- Older adults seldom exhibit the classic signs of a manic episode. Instead of dealing elated and displaying risky behaviors, older adults are more likely to show signs of agitation and irritability.
- Confusion
- Psychosis
- Hyperactivity
Bipolar Disorders: Assessment
- Thorough physical examination and laboratory and radiological testing to rule out physical causes of symptoms and identify comorbidities.
- Accurate individual and family history.
Bipolar Disorder: Genetics
There is a strong hereditary component to BD and a person with a parent or sibling with BD is four to six times more likely to develop the illness.
Bipolar Disorder: Pharmacotherapy
- Lithium
- Antidepressants
- Anticonvulsants
Bipolar Disorder: Psychosocial
- Intensive psychotherapy
- Cognitive behavior therapy
- Interpersonal and rhythm therapy
- Psychoeducation
Depression
Often associated with dependency and disability; however, depression is NOT a normal part of aging.
Depression: Racial, Ethnic and Cultural Considerations
- Hispanics aged 50 and older are reported to experience more depression than other groups.
- Older women suffer depression at twice the rate of older men.
Symptoms of Depression
- Sadness that persists for more than several weeks may be clinical depression.
- Signs of depression can be more varied and difficult to spot among older adults. Simply appear to be tired, grumpy or irritable.
Confusion and attention issues caused by depression can be mistaken for
Symptoms of Alzheimer’s disease or dementia.
Symptoms lasting more than 2 weeks may indicate
An older adult is suffering from depression
The following clues may signify that an older adult is suffering from depression but unwilling to accept or admit it:
- Persistent and vague complaints
- Help-seeking
- Moving in a slower manner
- Demanding behaviors
- Neglected personal care
Consequences of Depression
- Can cause disability and harm to an individual’s health and quality of life.
- Delayed recovery from illness and surgery
- Excess use of health services, cognitive impairment
- Exacerbation of co-existing medical illnesses
- Malnutrition
- Decreased quality of life
- Increased suicide death
Depression Etiology
- Factors of health, gender, developmental needs, socioeconomics, environment, personality, losses, and functional decline are all significant to the development of depression in later life.
- Neurotransmitter imbalances have strong association with many depressive disorders.
- Medical disorders and medications can result in depressive symptoms
Depression: Assessment
- Older people who are depressed report more somatic complaints such as insomnia, loss of appetite and weight loss, memory loss, or chronic pain.
- Hypochondriasis (obsession with the idea of having a serious but undiagnosed medical condition) is also common.
The goals of depression treatment in older adults are to
Decrease symptoms, reduce relapse and recurrence, improve function and quality of life and reduce mortality and health care costs.
Nonpharmacological Interventions of Depression
- PEARLS Program
- Collaborative Care
Pharmacological Interventions for Depression
- SSRIs
- SNRIs
Other treatments for depression include
- Electroconvulsive therapy
- Repetitive Transcranial Magentic Stimulation
Assessment for Suicide
- The lethality potential of an elder must always be assessed when elements of depression, disease, and spousal loss are evident
- Establish a trusting and respectful relationship with the person
- If there is suspicion that the elder is suicidal, use direct and straightforward questions
Suicide Interventions
- Have a suicide protocol in place if a positive response is obtained from any of the questions.
- The person should never be left alone for any period until help arrives to assist and care for the person.
- Patients at high risk should be hospitalized.
- Patients at moderate risk can be treated as outpatients provided they have adequate social support and no access to lethal means.
- Patients at low risk should have a full psychiatric evaluation and be followed carefully.
Alcohol Use Disorder: Gender Issues
- Men are four times more likely to abuse alcohol
- Women of all ages significantly more vulnerable to effects.
Alcohol Use: Physiology
-Older people develop higher blood alcohol levels because of changes of aging altering absorption/distribution.
Consequence of Alcohol Use Disorder
- Cirrhosis of the liver
- Cancer
- Immune disorders
- Cardiomyopathy
- Cerebral atrophy
- Dementia
- Delirium
- Many Drugs that elders use cause adverse effects when combined with alcohol
Alcohol Use Disorder: Assessment
- Short Michigan Alcoholism Screening Test
- Assessment of depression is important
- Signs and symptoms of potential alcohol problems
Reasons for the low rate of alcohol detection in older adults:
- Poor symptom recognition
- Inadequate knowledge about screening instruments
- Lack of age-appropriate diagnostic criteria for abuse in older people
- Ageism
Alcohol Use Disorder: Interventions
- Cognitive-behavioral therapy (form of psychotherapy that treats problems and boosts happiness by modifying dysfunctional emotions, behaviors, and thoughts)
- Individual and group counseling
- Medical and psychiatric approaches
- Alcoholics anonymous
- Family therapy
- Case management and community home care services
- Formalized substance abuse treatment
Acute Alcohol Withdrawal
- Withdrawal from Alcohol can become life-threatening emergency
- Detoxification should be done in an inpatient setting.
Acute Alcohol Withdrawal: Symptoms
Symptoms of acute alcohol withdrawal vary but may be more severe and last longer in older people.
Acute Alcohol Withdrawal: Reliable Screening Instrument
Clinical Institute Withdrawal Assessment scale is recommended as a valid and reliable screening instrument
Other Substance Abuse Concerns
- Misuse and abuse of prescription psychoactive medications.
- Dependence on sedative, hypnotic, or anxiolytic drugs.
- Opioids are ranked second to benzodiazepines among abused prescription drugs in older adults.
Pain and Aging
- Pain is NOT a normal part of aging.
- As one ages, acute pain occurs most often superimposed on preexisting persistent pain.
The most common type of pain in late life is
Persistent
Persons with persistent pain are more likely to be
Depressed and to have sleep disorders, but not all who are depressed have physical pain.
Inadequately treated persistent physical pain will almost always lead to
Impaired functional status and in some cognitive cases cognitive impairments.
Pain in the Older Adult
With aging there is a decrease in density of both myelinated and unmyelinated nerve fibers very slightly delaying sensation of pain from the periphery and there is slower resolution once triggered.
Pain in those with cognitive impairments
Are consistently untreated or undertreated for pain
Pain in patients with dementia
Those with dementia may have altered affective responses to pain, probably due to their inability to cognitively process the painful sensation in the context of prior pain experience, attitudes, knowledge, and beliefs
Pain Assessment
A high-quality comprehensive instrument incorporates the most important aspects of assessment and includes person’s self-report, and both qualitative and quantitative measures of comfort.
Iatrogenic Disturbance Pain describes
Pain caused by care provider: use of B/P cuff, bathing, moving and repositioning.
Rating the Intensity of Pain
- A key element of assessment is the intensity of pain perceived by the person; it is always what the person says it is.
- Rating scales have become the standard of care.
- Scales that are currently available and tested may not be reliable for persons with delirium or more severe impairments.
Assessment of Pain in Cognitively Impaired
- Persons with impaired communication skills with noncommunicative patients (Box 27-10, Touhy & Jett).
- It is recommended that attempts are made to use standard assessment instruments first even when the person has advanced dementia.
- The Pain Assessment in Advanced Dementia (PAINAD) Scale developed for use for those who either cannot express or cannot reliably express pain (Table 27-1, Touhy & Jett).
- PACSLAC-2: behavioral assessment tool that may be helpful as an initial pain screen.
Nonpharmacological Measures for Pain
- Energy/touch therapies
- Transcutaneous electrical nerve stimulation
- Acupuncture and acupressure
- Relaxation, meditation, and guided imagery
- Music
- Activity
- Cognitive-behavioral therapy
Pharmacological Interventions for Pain
- While treatment regimens vary, all are guided by the same underlying principles (Box 27-12, Touhy & Jett).
- The World Health Organization (WHO) introduced a progressive three-step ladder as a framework for the treatment of pain as it increases in intensity or modalities are found to be ineffective.
- To achieve the highest level of pain control, it is helpful to ease the “memory of pain,” especially when persistent pain is intense; meaning prevent pain, not simply relieve it.
WHO Step Ladder
…
Pharmacological Interventions for Pain
- Nonopioid Analgesics: Acetaminophen, NSAIDs
- Opioid Analgesics: Tramadol, oxycodone, hydromorphone. (Demerol contraindicated in the older adult)
- Adjuvant drugs: Corticosteroids, anxiolytics (i.e. benzodiazepines), hypnotics (i.e. zolpidem or Ambien), antidepressants (i.e. escitalopram or Lexapro), and anticonvulsants (gabapentin or Neurontin)
Pain Interventions: Evaluation of Effectiveness
- Effectiveness of any intervention designed to relieve pain is quantitatively measured with repeated use of the intensity scale; qualitative observations are supplemental to this.
- The nurse advocates for the person so that adjustments of treatment regimens and interventions are based on reassessment findings.
- “Start low, go slow, but go!”
