The Need for Mental Health Services for Older Adults - NOW!By James J Messina, Ph.D., NCC, CCMHC, DMHS-T
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Due to the retirement of the baby boomer generation between
2005 and 2030 the number of adults 65 and older in the United States has almost
doubled. This population shift in the age distribution of America’s population
has placed an accelerated demand on the U.S. health care system (Institute of
Medicine (IOM), 2008).
How has this shift in population impacted the health care
workforce in America? The Institute of Medicine (IOM) in 2008 predicted that
the sheer volume of older adult patients threatened to overwhelm the number of
physicians and other professionals who would be available to serve this aging
population. The Institute identified that specific skills sets are required to
treat these aging seniors and that there needs to be trained geriatricians to
meet these needs. The needs these aging seniors bring to the health care
industry are:
- Dealing
and coping with chronic illnesses
- Recovering
from the physical and emotional impact of physical falls
- Preventing
or surviving from malnutrition
- Dealing
with aging seniors’ cognitive impairments that can impact their ability to care
for themselves
- Dealing
with the care and health management of seniors with chronic conditions such as
hypertension and congestive heart failure (IOM, 2008).
IOM recommended that to improve the ability of the health
care workforce to care for older Americans the needs to be a three-pronged
approach:
- Enhance the competence of all individuals in the delivery of geriatric care
- Increase the recruitment and retention of geriatric specialists and caregivers
- Redesign models of care and broaden provider and patient roles to achieve greater flexibility (IOM, 2008).
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Ageism Hinders Providing Mental Health Services to Aging Seniors
Ageism was described as social stigma associated with old age or older people—which has deleterious effects on older adults’ physical health, psychological well-being, and self-perception (Fullen, 2018).
Ageism Stereotypes
Ageist attitudes can take multiple forms, sometimes discreet and often without intentional malice. Even people with severe dementia respond with behavioral resistance when spoken to in an infantilizing. There are many inaccurate stereotypes of older adults that can contribute to negative biases and affect the delivery of psychological services. For example, stereotypes include the views that
- with age inevitably comes dementia;
- older adults have high rates of mental illness, particularly depression;
- older adults are inefficient in the workplace;
- most older adults are frail and ill;
- older adults are socially isolated;
- older adults have no interest in sex or intimacy; and
- older adults are inflexible and stubborn.
The Dangers of Myths about Older Adults
APA identified the following Myths and Facts about older adults:
Myth: Dementia is an inevitable part of aging.
Fact: Most older adults are cognitively intact.
Myth: Older adults have higher rates of mental illness than younger adults, especially depression.
Fact: Older adults tend to have lower rates of depression than younger adults.
Myth: Older adults are a homogeneous group.
Fact: The aging population is a highly heterogeneous group.
Myth: Most older adults are frail and ill.
Fact: Most older adults have good functional health.
Myth: Older adults have no interest in sex or intimacy.
Fact: Most older adults have meaningful interpersonal and sexual relationships.
Myth: Older adults are inflexible and stubborn.
Fact: Most older adults have the same personality traits as at a younger age
(American Psychological Association, 2023).
It is important when working with aging seniors that therapist do not get caught in going down the dangerous path of agists’ beliefs in the myths about older adults and thus not taking their mental health issues seriously. This is just an unfortunate example of how agism interferes in getting aging seniors the mental health needs they have.
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Impact of Pain on Older Adults
Reports of pain by older adults need to be taken seriously because the pain could be a warning for severe underlying problems. Suffering from chronic pain can result in the following negative outcomes:
- Fatigue
- Nausea
- Loss of appetite
- Poor sleep
- Depression
- Limited daily activities
- Thoughts of dying
Chronic pain requires coordination of a medical team treating older adults to ass, treat and mange follow-up.
Unfortunately, an older person may not want to “complain” about. For this reason assessment of pain is important because pain may well be an indicator of a serious underlying medical condition (Health in Aging Foundation, 2022).
Many older adults live with at least one common illness that causes pain. These common conditions include:
- Joint diseases (arthritis)
- Diabetes
- Shingles
- Teeth or gum issues
- Stroke
- Cancer
- Muscle and blood vessel diseases
- Bone conditions
Non-medication treatment of pain can relieve pain and may reduce the need for medication. Some of these methods are interventions which mental health therapists can perform. They are:
- Cognitive-behavioral therapy such as self-hypnosis and coping strategies
- Reminiscence therapy (Coping.us, 2023)
- Relaxation methods, such as meditation, deep breathing exercises, yoga, and massage (Health in Aging Foundation, 2022).
Lifestyle changes and personal management of pain as recommended by the Health in Aging Foundation (2022) are:
- Staying Active – Staying involved in physical and social activities is important and will reduce the risk of depression and isolation.
- Maintaining a Good Diet - Having a good diet will help improve the way pain management drugs work, help reduce their side effects, and help to maintain the energy needed for daily activities.
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Impact of Loses Experienced by Aging Seniors
In coping.us (2023) the losses experienced by Aging Seniors over their lifetimes were identified and it is important that therapists working with the elderly screen in their therapy sessions to identify the losses experienced by their elderly clients such as:
- Having an “abnormal” childhood Loss involved: Loss of the childlike experiences due to the need to grow up too soon, taking on an adult role prematurely.
- Being unable to make it better in a new family Loss involved: Loss of the expectation or desire for things to be better in the new nuclear family than they were in their own family of origin; since trans-generational destructive patterns re-emerge.
- Living in an ”abnormal” or “dysfunctional” family Loss involved: Inability to achieve their fantasy or the dream expectation of “normal” family life while in their family of origin.
- Having an unhappy, nonproductive marriage Loss involved: Loss of the expectation of a happy, “normal” marriage when they confront the realities of the present or past marriage.
- Having other than “normal” healthy children Loss involved: Loss of the expectation of having children who are going to be better off than they were. When their children have ill health, a developmental disability, or have emotional or behavior problems, they grieve even more.
- Death of a spouse or child Loss involved: Loss of the loved one who was going to help them make their life better
- Death of a parent Loss involved: Losing the chance to make it right and get close to parent. Continued feelings of neglect, hurt, of not being “good enough” to get parent's attention, recognition, approval.
- Divorce Loss involved: Loss of the “ideal” marriage that was going to make things better. Loss of the idea of and hope for a lifelong partner.
- Financial troubles Loss involved: Loss of self-respect. Belief that one should provide financial security for self, spouse, and family is shattered.
- Loss of job, failure of private business or failure in school Loss involved: Loss of trust in self and others. Belief that one should provide a source of financial security or high-grade point average for family is shattered.
- Realization that stressful families of origin influence their current behavior Loss involved: Loss of comfort in memories of the past. Thoughts of the past become colored with the realities of delusion and denial present in families of origin.
- Confrontation of addictive behavior in their lives (e.g., alcohol, drugs, gambling, food, shopping, sex) Loss involved: Loss of ability to hide behind the denial and delusion that things in their lives were “normal.” Destructive patterns become clear
- Entering a treatment or rehabilitation program Loss involved: Loss of privacy, loss of being able to continue with non-confronted denial, repression, or delusional behavior.
- A family member enters a treatment program and responds well to the program Loss involved: Loss of expectation of problem behavior of person as being “normal” or characteristic of the person; loss of predictability of the person's behavior. Realization that “family secrets” are out in the light to others as a result of the family member’s recovery process.
- Occurrence of natural disaster or accident Loss involved: Loss of property, health, and security in things, people, or life.
- Physical or mental illness in family Loss involved: Loss of expectation of natural course of events for self and others. Family life turned upside down.
- Lack of recognition for accomplishments on the job, at school or in the community Loss involved: Loss of belief in their own self-worth and loss of incentive to continue trying. Reinforcement of the feeling that no matter what they do, it is not “good enough ”
- Realizing their loss of productivity on the job as they grow older Loss involved: Loss of self-worth and meaning based on the belief that their worth is built solely upon what they do on the job or for others.
- Older children move out of the house Loss involved: The “empty nest” is a sign of their no longer being needed, and they lose the “meaning” gained for themselves by rearing their children.
- Retirement Loss involved: Loss of self-worth and meaning of life based on their “work” which was their sole identity.
- Being personally moved into a Residential Treatment Center for either Independent Living, Assisted Living, Memory Unit or Nursing Home Loss Involved: Loss of independence and often personal identity due to being labeled as needing 24 hour care away from one’s personal home and/or family.
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Impact of the New DSM-5 TR Diagnosis of Complicated Grief Impacts Elderly
Complicated Grief and Aging Seniors is another factor which must be incorporated in the clinical assessment process when working with elderly clients according to Mayo Clinic (2022).
Description of Prolonged Grief
- Grief is a common, normal human emotion, and a natural reaction to loss.
- Grief affects everyone differently, It may be difficult to concentrate, perform normal activities, or sleep may be impaired. There may also be intense waves of different emotions or feeling intensely overwhelmed.
- Grief typically resolves within 6 to 12 months, but some people may continue to experience the symptoms of grief and develop prolonged grief disorder.
- Over time, they may see a decline in physical, emotional, or spiritual health. Symptoms of prolonged grief disorder include emotional numbness, intense emotional pain and loneliness, identity disruption, and disbelief about the person’s death.
- Grief can completely derail functioning. It is not linear and often shows up in unexpected ways. (Ries, 2022)
Complicated grief may be indicated if Aging Seniors
- Have trouble carrying out normal routines
- Isolate from others and withdraw from social activities
- Experience depression, deep sadness, guilt or self-blame
- Believe that they did something wrong or could have prevented the death
- Feel life isn't worth living without their loved one
- Wish they had died along with their loved one (Mayo, 2022)
Risk factors for Complicated Grief
It's not known what causes complicated grief. As with many mental health disorders, it may involve one’s environment, personality, inherited traits and one’ body's natural chemical makeup.
Complicated grief occurs more often in females and with aging seniors. Factors that may increase the risk of developing complicated grief include:
- An unexpected or violent death, such as death from a car accident, or the murder or suicide of a loved one
- Death of a child
- Close or dependent relationship to the deceased person
- Social isolation or loss of a support system or friendships
- History of depression, separation anxiety or post-traumatic stress disorder (PTSD)
- Traumatic childhood experiences, such as abuse or neglect
- Other major life stressors, such as major financial hardships (Mayo, 2022)
Unintended Consequences of Complicated Grief
Complicated grief can affect aging seniors physically, mentally and socially. Without appropriate treatment, complications may include:
- Depression
- Suicidal thoughts or behaviors
- Anxiety, including PTSD
- Significant sleep disturbances
- Increased risk of physical illness, such as heart disease, cancer or high blood pressure
- Long-term difficulty with daily living, relationships or work activities
- Alcohol, nicotine use or substance misuse (Mayo, 2022)
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Recommendations for Preparing to Work with Aging Seniors
It is important for counselors and therapists who are preparing to work with aging seniors to have a better understanding of the health needs of this population. There is a need to watch out for the impact of ageism which could hinder the intake and diagnosis process in working with this population. It is important to identify the impact of pain both chronic and situational physical pain has on aging seniors who are dealing with it and how it affects their outlook on life. Finally it is important to recognize that this population suffers and has suffered from a great deal of losses in their lives and that there is a need to be conscious of the impact of these losses on your aging case load.
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