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Gerontology Case Studies

Gerontology

A Training Resource

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T


The Gerontology Section Theme Song

We were luck on March 29, 2019 to hear Ben Platt sing one song from his new album which went public that day. His album is: Sing to Me Instead.  The song he sang on The Today Show was Older. Older is now the official Theme Song for our coping.us Gerontology Section. You can listen to it by going to: https://www.youtube.com/watch?v=P6YovA8N9Go
Directions:

Develop a complete Initial Clinical Assessment using the form below and consider, for your treatment planning, using  The Older Adult Psychotherapy Treatment Planner, with DSM-5 Updates, 2nd Edition (See box below) for each of these clients including:

  1. Why Now?
  2. Psychosocial History
  3. Mental Status
  4. ACE Factors
  5. What assessments you would use in this case
  6. Diagnosis: Principal; Provisional and Other Condition that May be a Focus of Clinical Attention
  7. Treatment Plan: 3 long term goals and for each goal 3 objectives and for each objective 1 intervention
Recommended Treatment Planning Book for working with Older Adults

Evidence Based Treatments for a Variety of Disorders

Experienced by Older Adults

The following book is highly recommended for any mental health professional setting out or currently working with older adults. This book covers the following issues with not only Evidence Based Treatment plans but also provides DSM-5 Diagnoses pertinent to each of the designated difficulties.

 

Frazer, D.W.. Hinrichsen, G.A. & Jongsma, A.E. (2015). The Older Adult Psychotherapy Treatment Planner, with DSM-5 Updates, 2nd Edition (PracticePlanners). John Wiley & Sons, Inc: Hoboken, New Jersey. (You can get this book on Amazon click here)


  • Activities of Daily Living
  • Anxiety
  • Caregiver Distress
  • Communication Deficits
  • Decisional Incapacity
  • Depression
  • Disruptive Behaviors in Dementia
  • Driving Deficits
  • Elder Abuse and Neglect
  • Falls
  • Interpersonal Dispurte
  • Life Role Transition
  • Loneliness/Interpersonal deficits
  • Mania/Hypomania
  • Medical/Medication Issues Unresolved
  • Obsessive-Compulsive Disorder (OCD)
  • Panic/Agoraphobia
  • Paranoid Ideation
  • Persistent Pain
  • Phobia
  • Residential Issues Unresolved
  • Sexually Inappropriate Behavior
  • Sleep Disturbance
  • Somatization
  • Spiritual Confusion
  • Substance Abuse/Dependence
  • Suicidal Ideation

 


Case 1: Mrs Brown

Mrs Brown is an 86-year-old lady who lives with her elderly husband. According to Mrs Brown husband they have two sons together and 3 grandchildren, they both visit occasionally. She used to work as a secretary until she retired in her early 60s.She clearly had a good memory. She enjoyed travelling abroad, with her husband. For many years she had attended services at the local church where she was well known .as a kind, warm-hearted popular lady in her town for the good things she did. She was diagnosed with dementia the Alzheimer disease 12 years ago. Alzheimer's is a brain disease that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks Her husband has been her main caregiver ever since. She attends a day center once a week and has caregivers coming in twice a week to assist with personal care. The staff at the day center has also reported that Mrs Brown now showed no interest and was reluctant to comply with activities which showed that she had lost sense of pleasure.

 

Mr Brown stated that before the diagnosis, they were several episodes when she got lost and was picked up by police to be returned at home. Mrs Brown became disorientated about where she was because of her dementia. She became confused about time. She will also miss her doctor's appointments. Mrs Brown couldn't even remember her son's names later on recognize her husband and would lose track of conversations. Mr Brown stated that he made an appointment then to see the general practitioner (GP) who then referred them to the memory clinic where she was diagnosed with Alzheimer.

 

In the last year Mrs Brown mental and physical health has deteriorated rapidly. She can no longer do her activities of daily living and she needs support with personal care. Her behavior has gradually become more and more eccentric that her husband is no longer coping. Mrs Brown was recently admitted to hospital with chest and urinary tract infection, which would also increase her level of confusion and lack of orientation. Although now discharged from hospital Mrs Brown's sleep pattern was disturbed, she now wanders around at night.

 

She has become more physical and verbally aggressive towards her husband, Mr Brown has raised concerns' that he can no longer cope with her behaviors. Mr Brown was considering looking for permanent placement in a nursing home for his wife

 

 

Client 2: Terry

Terry age 68, was diagnosed with Alzheimer's disease in 5 years ago after undergoing a series of tests and having to spend time in a psychiatric hospital. The time he spent in the hospital before his diagnosis was very difficult for him and his family, because unlike with other illnesses, Alzheimer's takes away sufferers' ability to think rationally. Terry did not fully understand why he was in the hospital with other people who had mental disorders, and at times he was very frustrated at not being allowed to go home.

 

After a trying few weeks and after undergoing weeks of tests, Terry was prescribed Aricept, a drug used to help slow down the progression of Alzheimer's disease. Terry has lived back at home ever since. He is constantly cared for by his wife of over 20 years Christine 62, Terry’s eldest daughter Sharon, who also plays a large part in Terry's life.

 

As part of a couple, there are many day-to-day tasks that are often split between the two people. When one half of the couple is struck down by a disease such as Alzheimer's, those tasks can no longer be equally shared, and more pressure falls on the other half of the couple as well as the family as a whole. When Terry could not drive anymore, it became Christine's responsibility as the sole driver as Terry can no longer drive; just a few months ago after fastening Terry into the car and walking around to the driver's side, he had released the handbrake in confusion over his seatbelt holder.

 

It can be very upsetting to deal with the different aspects of the illness, as the sufferer sometimes forgets the names of those closest to them, or maybe even the fact they are married or have children. These are the times when it is vital to remember that it is the illness talking, not your loved one. Having to explain to someone where they live, who they are married to and even the names of their friends and family is perhaps one of the most heartbreaking things for a family to endure.

 

At times, Terry has questioned his relation to Christine and there even came a time when he dialed 911 to ask about the welfare of one of his daughters as he had not seen her for a while.

 

Familiarity is usually the key when dealing with Alzheimer's; if the surroundings and people are the same then they can develop some sense of routine - a word that is crucial to the day-to-day life of someone living as a identified patient or caregiver.. However, sometimes it can also be good to have a short break, as Christine and Terry found out when they went to a holiday respite center last month. They went as part of a respite plan offered by the Alzheimer's society, and spent the week being looked after by professionals. As well as giving them both a change of scenery, it offered lots of activities for them to take part in as well as day trips and was fully equipped with qualified caregivers to deal with Alzheimer's clients, taking some of the pressure off Christine.

 

It is often said that with Alzheimer's there are 'good days' and 'bad days' and it is true up to a point. However, the good days are not as good as they once would have been, and unfortunately once Alzhiemer's takes over, the person you once knew becomes a shadow of their former selves.

 

Another problem that can arise when spending time with someone suffering from Alzhiemer's is that they can very quickly become paranoid, for example if someone laughs they might think it is directed at them, causing them to become irate. This can make it hard to socialize as normal without making them feel uncomfortable, and it is important to keep their feelings in mind at all times.

 

While dealing with Alzheimer's is no walk in the park, it is something that must be done, and it does have light moments. For all of the difficult times and the sadness faced there are times when the person suffering from Alzheimer's will show a flash of their personality as it used to be. These are the times that Terry's family have cherished and will continue to cherish throughout his illness. Perhaps in a conversation about one of his favorite television shows or when talking about football he will let out a little quip, a quick-witted comment and remind everyone that his sense of humor remains very much intact, if a little distorted at times. Sharing a joke with a loved one is always a special moment, but in these circumstances; it is made even more precious.

 

 

Case 3: Miriam

After her husband died two years ago, Miriam a retired social worker who is now 87, moved into an independent living facility. It was a difficult transition to make late in life.

“It was really strange to me, and I couldn’t seem to make any friends here,” Miriam. said. “I really couldn’t find my way. I was having a terrible time.”

 

A doctor at the center told her that her problems were not unusual for someone in her situation and encouraged her to make some friends. He prescribed Xanax to help with anxiety, which she said she rarely takes, and he put her in touch with a social worker, whom Mariam saw once a week until the social worker moved (Mariam now has a new social worker she talks to). They strategized on how she could reach out. And slowly, she did.

 

“Sitting at the table for dinner, you talk to people,” said Miriam, who has become president of her building.

 

Case 4: Judith

After a debilitating depression in which she spent three months unable to get out of bed, Judith, 69, of Small Town, Fla., decided to see a doctor who prescribed medication. (She also tried group therapy but didn’t like it.) He also practiced some cognitive behavioral techniques with her — for instance, requiring her to get dressed every day for a minimum of 15 minutes.

 

Eventually, she began to feel better. “I learned to adjust my thinking, and I don’t get as anxious as I used to,” said Judith, who has since begun making and selling jewelry. “I found out at this age that I am artistic and creative and innovative and smart. I just woke up to the fact that I have a mind of my own. Talk about a late bloomer.”

 

Her doctor who still meets with Judith monthly, said, “You might not be able to gain a magical insight and wrap up their entire life in therapy, but you might be able to accomplish one or two small but meaningful goals.”

 

Case 5: Marvin

Marvin was 83 when he decided that the unexamined life wasn’t worth living. Until then, it had never occurred to him that there might be emotional “issues” he wanted to explore with a counselor. “I don’t think I ever needed therapy,” said Marvin a retired manufacturer of women’s undergarments who lives suburban New York.. Though he wasn’t clinically depressed, Marvin did suffer from migraines and “struggled through a lot of things in my life” — the demise of a long-term business partnership, the sudden death of his first wife 18 years ago. He worried about his children and grandchildren, and his relationship with his current wife, Carole.


“When I hit my 80s I thought, ‘The hell with this.’ I don’t know how long I’m going to live, I want to make it easier,” said Marvin, now 86. “Everybody needs help, and everybody makes mistakes. I needed to reach outside my own capabilities.”


So Marvin began seeing a counselor. They meet once a month for 45 minutes, exploring the problems that were weighing on Marvin. “My counselor is giving me a perspective that I didn’t think about,” he said. “It’s been making the transition of living at this age in relation to my family very doable and very livable.” Marvin is one of many seniors who are seeking psychological help late in life. Most never set foot near a counselor’s couch in their younger years. But now, as people are living longer, and the stigma of psychological counseling has diminished, they are recognizing that their golden years might be easier if they alleviate the problems they have been carrying around for decades. It also helps that Medicare pays for psychiatric assessments and therapy.

 

Therapists have been seeing more people in their 80s and older over the past few years, many who have never done therapy before. Usually, they’ve tried other resources like their church, or talked to family. They’re realizing that they’re living longer, and if you’ve got another 10 or 15 years, why be miserable if there’s something that can help you?”

 

Some of these older patients are clinically depressed. The National Alliance on Mental Illness reports that more than 6.5 million Americans over age 65 suffer from depression. But many are grappling with mental health issues unaddressed for decades, as well as contemporary concerns about new living arrangements, finances, chronic health problems, the loss of loved ones and their own mortality. “It’s never too late, if someone has never dealt with issues,” said a therapist in New York who works almost exclusively with older patients, many of whom are seeking help for the first time. “A combination of stresses late in life can bring up problems that weren’t resolved.”

 

Marvin’s counselor said: “Things can be seen differently from the perspective of old age that relieve some guilt and challenge assumptions that you’ve had for decades. Maybe it wasn’t too terrible after all; maybe I shouldn’t blame myself.’ Maybe some of your worst mistakes weren’t so egregious, and maybe there were unavoidable circumstances you couldn’t control.”

 

Marvin still stops by his counselor’s office for a monthly checkup. “Everybody has a certain amount of heartache in life — it’s how you handle the heartache that is the essential core of your life,” Marvin said. “I found that my attitude was important, and I had to reinforce positive things all the time.” He said he wishes he had tried therapy years ago. But he adds: “I can’t go back. I can only go forward.”

Case 6: Rosie

Rosie is an elderly woman and is presently sitting across from you.  She is dressed nicely and is patiently waiting for you to speak. She has only told you that her husband wanted her to come in to see you. Her medical doctor has run a complete laboratory exam and found nothing of importance. A CAT scan reveals that the brain is atrophied. Rosie’s mother had Alzheimer's disease.


Rosie is 73 years old. Rosie is absent-minded.  She has had no bizarre thoughts.

Rosie rationalizes away her forgetfulness. Rosie’s judgment seems impaired as she has thrown away valuables. Rosie interprets proverbs concretely. She has no focal neurological signs. Rosie is friendly but less social lately.


Rosie often asks you to repeat questions. She often leaves water running and the stove on all day. Her husband Charlie and Rosie fight about her forgetfulness.  No physical harm is done. Rosie’s son has been trying to get her committed to a care home. Charlie has begun to give up on her. Charlie can not afford to send Rosie to a nice nursing home. She does not have the sparkle she used to have.  She is shyer now. She sometimes forgets who people are which causes embarrassing situations. She is slightly subdued lately. She sometimes says the strangest things to strangers. Occasionally she will become irate but she is not depressed. Usually she is subdued. She recently was found shopping at 2 am for bananas. She does not seem to laugh much lately. Her husband is partially disabled with a bad back. Rosie and Charlie have lived in the same comfortable suburban home for 20 years. Their children all live out of town.


Charlie noticed a slight absent-mindedness about 4 years ago. She has progressively become more absent-minded over last 4 years. Her judgment has been impaired for the last year. She has forgotten names of family members for the last 6 months.

 

Case 7: Gloria

Gloria, your client across from you is in her mid-60's and is very neatly dressed.  You notice that Gloria is on the thin side and shakes slightly. You ask her: What can I do for you?”. Gloria says: “Well, my minister thought I might speak to you.  Actually, he recommended someone else but he was too busy.  So, I called you as you seem to have more time free.  Do you believe in Jesus? You respond: “Is it important to you that I am a Christian counselor?” Gloria says: “No.  It depends on your beliefs.  Our church says that if you drink it is because of the devil.  Do you believe in the devil?”


Gloria has been involved in three major accidents in the last 5 years.  Gloria managed to recover in good health from each one. Her doctor advised her that continued use of alcohol would ruin her health. Gloria saw a psychologist for several years when Gloria divorced her first husband.

 

Gloria has reported some mild hallucinations during the last several days. Gloria seems of normal intelligence and had no trouble following your conversation. Gloria rambles on and on at times. Gloria has fits of tremors in her hands and eyelids. Gloria vomited in your waiting room but you have not found this out yet. Gloria complains of a bad headache. She says her sleep is very fitful.

 

Her current religious leader has insisted that Gloria fast to get rid of her urges for alcohol. Her husband will not attend church services with her. Gloria can't reconcile her drinking with her religious beliefs.Gloria is a follower of others. Gloria will usually never say “no” even to herself. Gloria is big with denial.

 

Sometimes Gloria is slightly depressed. Gloria is not usually irritable but lately has been. Gloria is a heavy drinker of alcoholic beverages. Her friend all drink rather heavily. Her parents were alcoholics. Her present symptoms have been present off and on for 4 days. Gloria told her minister that Gloria stopped drinking 4 days ago but Gloria started again and did not stop until yesterday. Gloria reports that she has been drinking alcohol for her 'whole life.'

 

Case 8: Joseph

Joseph was very hesitant in talking to the psychologist about his problems. Joseph is a Middle School English teacher Joseph’s school principal where referred him.  His principal noticed that Joseph was complaining about his heart problems and seemed out of sorts lately.  Although this psychologist is familiar with the DSM-5, the psychologist is also hesitant to make a diagnosis.

 

Joseph is 55 years old. He recently has been having some heart problems, although nothing serious yet. He has been very dissatisfied with his sexual relations with his wife for many years now. Joseph has had some problems with impotency.

 

Joseph finds himself daydreaming often at work and at home. He is of normal intelligence. His daydreams are of sexual encounters with little girls. He constantly belittles himself. He is sweating and stumbles for his words while relating his problem to you. His sexual functioning is normal. He is neat in appearance and very polite. He says that he has never actually carried out his sexual fantasies with children. He does not want to die without leaving his family in a more secure position. The little children in his fantasies remind him of his own children. His wife seems to be turning into what he calls an “old woman” before he is ready to become an “old man”.

 

Joseph’s teaching is suffering and his principal has noticed. He is warm and friendly to almost everyone. He has a tendency to overlook others faults and internalize them. He does not like to talk about “secret” or emotional topics. He is awkward at parties. He seems to be slightly depressed. He has never hit anyone or caused harm to his recollection. He says that he has never acted out his sexual fantasies.

 

Joseph had a summer job several years ago where his fellow workers exposed him to pornographic movies. He finds that he enjoys these fantasies more than sex with his wife. His wife is cold and distant. He lives in a small town. He has been having these fantasies for about two years. He has been having problems with his wife for about ten years with more problems occurring after learning of his heart condition. He learned of his heart condition about two years ago.

 

Case 9: Mrs Smith

Dear Counselor,

It has been a long time since I've seen you.  I hope all are fine with your program in Florida. I'm writing as I have a client (Mrs. Smith) who is moving to your town and I would like for you to begin seeing her or find a competent therapist for her.  She is 72 years old and recently widowed.  She has an active social life and volunteers at local hospitals and other agencies.  She is moving because her current boyfriend (Tom) wants to work in your town.

 

Tom is 24 years old and they are engaged.  Mrs. Smith's children are very concerned about their mother and have convinced her to begin therapy.  She only saw me for 2 visits and was not too happy about seeing a therapist as she doesn't believe that one can help.

 

She has not had previous therapy.  She is very talkative and will often speak very rapidly.  She has, of course, mentioned that she believes that her children are trying to get her declared insane so they can get to her money.  Her children say that this talkative and almost hostile manner is quite different from her previous way of relating to others.  She often approaches strangers to let them know how happy she is.  This is in sharp contrast to the conventional way that she was raised. It seems that these mannerisms started shortly after her husband's death about 1 year ago and reached a climax about 3 months ago.  Her behavior has not changed but has stayed about the same.  I hope that this short description will help you get off to a better start than I did.

Sincerely Yours,

Your Worried Colleague

 

Background

Mrs. Smith has had a complete check-up with no serious complications present when a tumor was removed 6 months ago.

She has no drug history and does not report any now.

Her vision is such that she cannot legally drive even with glasses.

She can still swim well and is in fairly good shape for her age.

She seems to be clear headed; reports no bizarre thoughts or visions.

Her thoughts seem to race from one subject to another on occasions.

It is relatively easy to distract her.

She would not take any test for mental abilities.

She sleeps only 3 to 4 hours per night.

She spends many evenings dancing at bars with her fiancé.

She is easily irritated if interrupted yet interrupts others often.

Her daily routine has changed drastically over the last year.

She is afraid that there is not enough time for her to do everything.

Her fiancé is also seeing other women.

She does not want to be counseled.

Her children seem to be constantly badgering her.

She is abusive and demanding.

She wants others to visit her often and on her demand.

She wants others to join in on her bizarre ideas and trips.

She often attempts to be seductive.

There has been no indication of remorse or sadness over her husband's death.

Her mood is very euphoric and fast paced.

She insists that she is very happy.

On an impulse she will give money away or become angry over a price being asked for something she desires.

She has never been on her own or 'free' (Mother or Husband were the boss).

Her life style until 1 year ago was very sheltered.

She has lots of money and this is well known in the community.

Her children were raised in foreign schools and are not close to her.

The length of symptoms is about 6 to 9 months.

There have been no remissions.

Her lack of sleep seems to be slowing her down during the last 2 weeks.

 

Case 10: Robert

Identified Client: Robert is a 66-year-old male, who retired for the past 4 years. He is a husband, father, grandfather, and friend.

Drug of Choice: Alcohol

Initial contact: Harriet, Robert's adult daughter, made the initial contact asking whether or not Family Intervention might be an option in trying to get her father some help for his drinking problem. Because this family lives in a large city on the West Coast, the initial interview was done over the phone.

Client History: "The drinking got worse after Robert retired, or maybe I started noticing it more." Robert has been married to Colleen for 44 years. They raised 2 daughters, numerous pets, and have lived in the same house for the past 35 years. Some things have changed in their marriage such as they now sleep in separate bedrooms; mostly because of Robert's drinking.

 

Robert would begin drinking in the late mornings just as soon as he could get his chores and errands done.

 

Robert and Colleen began to have less and less to talk about as time went by. Colleen didn't want to talk to Robert when he had been drinking and it began to seem like he was always drinking. And Robert really didn't have much to say to Colleen. She was always coming and going and when she did stick around it seemed as though she just had something negative to say about what he was doing or not doing, "Have you been drinking?" He felt like all she did was nag.

 

"The drinking got worse after Robert retired or maybe I started noticing it more" complained Colleen. Robert began to go to bed earlier and earlier. "Now that I look back at it, I think he went off to bed to be able to drink and not have me on his back."

Some health issues began to arise, complicated by years of drinking. Roberts' doctor was having him get his blood tested every 3 months to monitor his diabetes and prostrate concerns. The doctor had long ago told Robert to stop drinking.

Harriet (Robert's daughter) stated that others were concerned about her dads drinking as well.