What Geriatric Therapists Need to Know about Older Adults
By James J Messina, Ph.D., NCC, CCMHC, DCMHS-T
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Introduction
What do mental health professionals need to know about serving aging seniors. This is especially true for mental health counselors and marriage and family therapists whose services to aging seniors as of January 2024 are now covered by Medicare? Here are some answers to this question:
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The State of Aging Seniors’ Mental Health
The CDC and the National Association of Chronic Disease Directors in 2008 published a report entitled “The State of Mental Health and Aging in America.” This report utilized the Behavioral Risk Factor Surveillance System and Indicators (BRFSS) in their determination of the mental health needs of seniors. What follows are significant findings from this 2008 report:
Social and Emotional Support
The percentages 7.8 to 17.74 of adults aged 50 or older across all states reported that they “rarely” or “never received the social support needed.”
Life Satisfaction
The percentages 4.06 to 7.16 of adults aged 50 or older across all states reported that they were “dissatisfied” or “very dissatisfied “with their lives.
Frequent Mental Distress
The percentages 7.23 to 14.45 of adults aged 50 or older across all states who in the past 30 days experienced frequent mental distress.
Current Depression
The percentages 5.41 to 12.43 of adults aged 50 or older across all states had current depression.
Lifetime Diagnosis of Depression across all states
The percentages 14.22 to 23.19 of adults aged 50 or older across all states with a lifetime diagnosis of depression.
Lifetime Diagnosis of Anxiety Disorder
The percentages 9.38 to 17.62 of adults aged 50 or older across all states with a lifetime diagnosis of anxiety disorder.
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Impact of Ageism on Older Adults
What is ageism?
The American Psychological Association Committee on Aging (APA CONA) defines ageism as “stereotyping and discrimination against individuals or groups based on their age. It can include:
- Prejudicial attitudes
- Discriminatory practices
- Institutional polices and practices that perpetuate stereotypical beliefs.“ (DeAngelis, 2022).
Ageism abounds in all areas of life, including media messaging, personal encounters, and internalized ageism—one’s own acceptance of negative notions about aging (for example, that feeling lonely, sad, or depressed is an inevitable part of getting older) (DeAngelis, 2022).
Ageism is harmful
People with a positive view of aging live 7.5 years longer that those with a negative view of aging (Levy et al., 2002). This is one reason why it is important for therapists to work at countering ageism in the thinking of their older adult clients.
- Ageism has been shown to cause cardiovascular stress, lowered levels of self-efficacy and decreased productivity in older adults.
- When older adults internalize ageism, ageist thoughts can become self-fulfilling by promoting in older people stereotypes of social isolation, physical and cognitive decline, lack of activity and economic burden’
- As a result of ageism, mental health and medical providers are less likely to identify mental health and medical concerns, due to the false belief that conditions like dementia or depression are typical with aging, and as a result providers are less likely to refer older adults to treatment or specialized care (Center for Mental Health and Aging, 2024).
There are three types of Ageism
- Hostile Ageism: This is the most overt type of ageism, which shows up in the form of physical, financial, and verbal abuse. It is also implicated in the perception of older adults as a drain on societal resources. The term “Silver Tsunami” that is used to describe the baby boomer population “flooding” society and depleting all of its resources is one example.
- Neglectful Ageism: This is a variation of ageism that overlooks the contributions of older adults and makes them invisible.
- Benevolent Ageism: This is a compassionate but paternalistic point of view, grouping older adults together as one uniformly frail and vulnerable population requiring protection (e.g., “Coronavirus: Isolate the Elderly”), This type of ageism is harmful in that it degrades an individual’s sense of self-efficacy ((Center for Mental Health and Aging, 2024).
Reframe Aging: Here are tips on how to choose your works to reframe aging from Reframing Aging (2024):
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Instead of these words and Cues:
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Try:
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“Tidal wave,” “Tsunami,” and similarly
Catastrophic terms for growing population of older people
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Talking affirmatively about changing demographics:”As Americans live longer and healthier lives…”
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“Choice,” “planning,” “control,” and other individual determinants of aging outcomes
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Emphasizing how to improve social contexts: “Let’s find creative solutions to ensure we can all thrive as we age.”
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“Seniors,” “elderly,” “aging dependents,” and similar “other-ing” terms that stoke stereotypes
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Using more neutral (“older people/Americans”) and inclusive (“we” and “us”) terms
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“Struggle,” “battle,” “fight,” and similar conflict-oriented words to describe aging experiences
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The Building Momentum metaphor: “Aging is a dynamic process that leads to new abilities and knowledge we can share with our communities.”
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Using the word “ageism” without explanation
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Defining ageism: “Ageism is discrimination against older people due to negative and inaccurate stereotypes.”
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Making generic appeals to the need to “do something” about aging
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Using concrete examples like intergenerational community centers to illustrate inventive solutions
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The most common mental health issues for people over 50
Depression. Risk factors include chronic physical illness and/or pain, diminishing physical functioning, grief and loss, and medications.
Anxiety disorders. Traumatic events, social isolation, medical issues, financial concerns and/or impaired memory can increase anxiety in older adults.
Dementia. Age, high blood pressure, diabetes, strokes, sedentary lifestyle, head injury, and alcohol abuse are all factors in the development of dementia. After 65, the likelihood of developing some form of dementia increases every five years and by age 85, more than 50 percent of people are affected.
Substance abuse or misuse. According to the Institute of Medicine, an estimated 14 to 20 percent of seniors have one or more mental health conditions resulting from misuse or abuse of medications, alcohol or other substances (WorkHealthLife, 2019).
Caregiving. There’s another factor affecting the mental health of many Boomers: caregiving. Because of advances in medicine and better living conditions, people are living longer and more and more Boomers find themselves caring for elderly parents, often in their 90s. Boomers may think they can do it all, even as they enter their senior years, but a lifetime of doing so is putting their physical and certainly mental health at risk (WorkHealthLife, 2019).
Adjustment to losses. Areas of concern for Baby Boomers include everything from retirement transition clear through to the end of life. One of the central issues that the elderly must cope with is loss. Most people get their first experience with death as children. However, people deal with death much more frequently in their senior years. Particularly difficult are the losses of spouse and lifelong friends. Other losses aging Baby Boomers face are physical: impairments in hearing, vision, or mobility and worsening of overall health. If they live long enough, many individuals also deal with the loss of independence and, to some degree, dignity (Careers in Psychology, 2019).
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The Stages of Aging for Baby Boomers
First Stage. Independence.
In the first stage, they are generally self-reliant and sufficient. They still have the ability to manage simple health problems, chronic ailments and disabilities. They can rely on Their own capabilities and do not need help from loved ones.
This is the right time for Baby Boomers to “assess their place and community” to know whether they will be reliable and supportive to them once the aging process takes a toll on them. In their years of independence, they should already be looking out closely for their health and the kind of care they may eventually need in the future. Where would they live the rest of their lives? They need to consider options such as long-term care, assisted living, or an affordable nursing home. They need to plan their our finances to cover their future. They need to put effort in preparing documents like will and testament or a power of attorney. They need to find ways to self-advocate.
Second Stage. Interdependence
This is the stage in Baby Boomers’ older adult lives when they are in need of help with basic tasks such as cleaning, doing house chores and other menial tasks. The importance of interdependence is important. This stage may be difficult but nowadays, there are increasingly more options coming up as more and more boomers are finding themselves in the same predicament. Usually, hiring caregivers and domestic helpers may be an option. Group homes and communes are also convenient. Looking for independent living facilities and homes that have strict security, clean rooms, decent meals, laundry services and cleaning service is also highly recommended.
Third Stage. Dependence.
This stage is when Baby Boomers are in dire need of others to help them with basic daily living activities such as dressing, preparing meals, bathing, grooming, driving, cleaning, shopping and even walking. Boomers can consider continuing-care retirement community in the stage of dependence. These kinds of facilities offer different living arrangements for different people needing care in all stages of their lives.
Fourth Stage. Crisis Management.
This is the stage where Baby Boomers may be in need of greater care and they may find themselves gravely dependent on health professionals and medical institutions to provide their medical necessities. For older adults who already have chronic ailments early in life or those with a family disposition to certain ailments related to aging, preparing for a crisis in the last stages of their life should be planned well. They must be prepared financially for this, most especially if they are living alone. Cognitive impairments may debilitate them in making decisions for themselves once the crisis starts.
Fifth Stage. Institutional Care.
The last stage is when Baby Boomers may be in need of extensive medical and personal care. This type of care may be provided by a nursing home or a hospice. Before this period, it is best that they have already prepared a “Durable Medical Power of Attorney” that will make legal decisions about their medical care needs. This will be especially helpful when they may be incapable of communicating or understanding what’s happening around them. The Durable Medical Power of Attorney will make a trusted person (preferably someone they chose) be in charge of overseeing their medical care and make proper health care decisions for them. It includes making decisions on their tests, medications, hydration, nourishment, doctors, hospitals, surgery and rehabilitation facilities they need. (SeniorLiving.org, 2018)
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Memory Loss Warning Signs
1. Memory loss that disrupts daily life: Forgetting recently learned information, forgetting dates or events and asking for the same information over and over again.
2. Challenges with planning or solving problems: Changes in ability to develop and follow a plan or work with number. May have trouble following a familiar recipe or keeping track of monthly bills or counting change.
3. Difficulty completing familiar tasks at home or work: Trouble driving to a familiar location, managing a budget at work or remembering the rules of a favorite game
4. Confusion with time or place: Losing track of dates and time, trouble understanding something if it is not happening immediately, or sometimes forgetting where one is or how one got there.
5. Trouble understanding visual images and spatial relationships: may have difficulty reading, judging distance and determining color or contrast, which may cause problems with driving.
6. Misplacing things and losing the ability to retrace steps: may put things in unusual places and lose things and be unable to go back over their steps to find them again.
7. New problems with words in speaking or writing: Trouble following or joining a conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves.
8. Decreased or poor judgment: May use poor judgment when dealing with money, giving large amounts to telemarketers. They may also pay less attention to grooming or keeping themselves clean.
9. Withdrawal from work or social activities: May start to remove themselves from hobbies, social activities, work projects or sports. They may have trouble keeping up with their favorite sports team.
10. Changes in mood and personality: May become confused, suspicious, depressed, fearful or anxious. They may appear to be easily upset at home, at work, with friends or in places where they are out of their comfort zones.
Note: It is normal for an older adult to forget where they put their keys, look all over for their glasses, then realize that they’re wearing them, or have trouble remembering someone’s name. But there are times when memory loss can be really scary and concerning. The above five examples are warning signs to help identify if memory loss is a problem and if it needs further medical or therapeutic evaluation (Center for Mental health and Aging, 2024).
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Warning Signs of Depression in Older Adults
Here are 10 Warning Signs of Depression in Older Adults:
1. Restlessness (like pacing and fidgeting, or the opposite, being usually still
2. Changes in sleep, like sleeping too much or too little
3. Feeling worthless or helpless
4. Feeling slowed down
5. Weight changes (due to changes in appetite – like gaining weight or losing weight
6. Physical symptoms such as pain or GI problems
7. Excessive worries about finances and health problems
8. Persistent sadness or crying a lot
9. Difficulty concentrating
10. Withdrawal from friends or social activities
Note: Many memory loss and depression symptoms overlap. To complicate things, these symptoms also overlap with medical problems. This reality is the reason that it is extremely important to seek professional medical consultation to uncover what is causing these symptoms (Center for Mental health and Aging, 2024).
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Competencies Needed to Address Mental Health Needs of Aging Adults
The Pikes Peak Geropsychology Competencies Guidelines
Competencies for professional geropsychology practice were delineated in 2006 (Knight et al, 2009). These competencies were aspirational rather than required of any particular mental health practitioner. These competencies are applicable across varied geriatric care settings and populations. The knowledge and skill competencies reflect core geropsychology practice attitudes, including recognition of scope of competence, self-awareness of attitudes and beliefs about aging and older adults, appreciation of diversity among older adults and commitment to continuing education (Knight et al, 2009). There are five Major Areas of competencies identified in the Pikes Peak measures:
1. Knowledge about adult development, aging and older adult populations
- Models of Aging
- Demographics
- Normal Aging – Biological, Psychological, Social Aspects
- Diversity in Aging Experience
2: Foundations of Professional Geriatric Clinical Practice
A. Knowledge base – Geriatric Therapists/Trainees need to have knowledge of:
- Neuroscience of aging
- Functional Changes
- Person-Environment Interaction and Adaptation
- Psychopathology
- Medical Illness
- End of Life Issues
B. Foundational Skills - The Geriatric therapist/Trainee is able to:
- Apply Ethical and Legal Standards by identifying, analyzing and addressing:
- Address Cultural and Individual Diversity with older adults, families, communities, and systems/providers by being able to:
- Recognize Importance of Teams
- Practice Self-Reflection
- Relate Effectively and Empathically
- Apply Scientific Knowledge
- Practice Appropriated Business in Geropsychology
- Advocate and Provide Care Coordination
3: Assessment
A. Knowledge base – Geriatric Therapist/Trainee has knowledge of:
- Geropsychology Assessment Methods
- Limitations of Assessment Methods
- Contextual Issues in Geropsychology Assessment
B. Skills – The Geriatric Therapist/Trainee is able to:
- Conduct Clinical Assessment and Differential Diagnosis
- Utilize Screening Instruments
- Refer for Other Evaluations as Indicated
- Utilize Cognitive Assessments
- Evaluate Decision Making and Functional Capacity
- Assess Risk
- Communicate Assessment Results and Recommendations
4. Intervention
A. Knowledge-The Geriatric Therapist/Trainee has knowledge of: Theory, Research, and Practice
- Health, Illness and Pharmacology
- Specific Settings
- Aging Services
- Ethical and Legal Standards
B. Skills – The Geriatric Therapist/Trainee is able to:
- Apply Individual, Group, and Family interventions
- Base Interventions on Empirical Research, Theory, and Clinical Judgement
- Use Available Evidence-based Treatments for Older Adults
- Use of Late Life Interventions – Provide effective, evidence-based interventions for particular issues affecting older adults
- Use Health-Enhancing Interventions
- Intervene across Settings
5. Consultation
A. Knowledge Base – The Geriatric Therapist/Trainee has knowledge of:
- Prevention and Health Promotion
- Diverse Clientele and Contexts
- Interdisciplinary Collaboration
B. Skills – The Geriatric Therapist/Trainee is able to:
- Provide Geropsychological Consultation
- Provide Training
- Participate in Interprofessional Teams
- Communicate Geropsychological Conceptualizations
- Implement Organizational Change
- Participate in a Variety of Models of Aging Services Delivery
- Collaborate and Coordinate with Agencies and Professionals
- Recognize and Negotiate Multiple Roles
Note: you can download the complete most updated version by going to the Pikes Peak Evaluation Tool at GeroCentral at: https://gerocentral.org/competencies/
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The AMHCA Guidelines For Working with Older Adults
The American Mental Health Counselors in 2021 developed a set of competencies which Licensed Mental Health Counselors would need to provide those aging seniors who hopefully would be eligible to receive their services once Medicare coverage is provided to seniors (AMHCA, 2023). Now in 2024 LMHC’s are able to put the following salient points from the AMHCA standards for: Aging and Older Adults Counseling Standards and Competencies into practice as Medicare providers.
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Aging and Older Adults Counseling Standards and Competencies
Older adults, those aged 60 or above, make important contributions to society as family members, volunteers and as active participants in the workforce. While most have good mental health, many older adults are at risk of developing mental disorders, neurological disorders or substance use problems as well as other health conditions such as diabetes, hearing loss, and osteoarthritis, to name but a few illnesses that may present in older persons. Furthermore, as people age, they are more likely to experience several conditions at the same time. The key components to successful aging include physical health, mental activity, social engagement, productivity and life satisfaction. When any one of these components are compromised, it can have a negative impact on quality of life. MHC’s must understand and address the interaction of these components when working with aging adults. In addition, older adults are more likely to experience events such as bereavement, a reduction in one’s socioeconomic status with retirement, or a disabling condition. All of these factors can result in isolation, loss of independence, loneliness and psychological distress in older adults. Mental health problems can be under-identified by health care professionals and older adults themselves, and the stigma surrounding mental illness can make older adults reluctant to seek help. Substance use problems among the elderly can also be overlooked or misdiagnosed.
1. Knowledge
LCMHCs in this area of specialization should demonstrate knowledge of the following physical and mental health subject areas specific to working with older adults:
a. Understand life span developmental theories relating to older adults.
b. Understand social processes, including topics such as the cultural context of relationships, social engagement and support, leisure and recreation, isolation, productivity (i.e., retirement, loss of identity), sexuality, intimacy, caregiving, self-care, stress relief, abuse and neglect, victimization, and loss and grief.
c. Understand skills necessary to cope with the emotional and physical challenges associated with the aging process, including how society responds to older adults.
d. Appreciate psychological aspects of aging, including topics related to the meaning and end of human life according to various religious and cultural viewpoints in relation to topics such as the quality and sacredness of life, end-of-life moral issues, grief and mourning, satisfaction and regret, suicide, and perspectives on life after death.
e. Recognize and have knowledge of the incidence of suicide among older persons, including warnings signs, risk factors, protective factors, acute vs. chronic risk, the ability to formulate the level of suicidal risk (none, low, moderate, high) using qualified assessment techniques, and managing risk.
f. Appreciate cultural and ethnic differences among older adults, including culturally relevant strategies to promote resilience and wellness in older adults.
g. Understand the integration and adjustment of life transitions that occur as part of normal aging (i.e., functional mobility, family constellation, housing, health care, level of care etc.).
h. Recognize the comorbidity of aging-related and health-related vulnerabilities and strengths.
i. Recognize the interplay between general medical conditions and mental health, including an understanding of common medications, side effects, drug interactions, and presentation.
j. Understand drug use and misuse among older adults. AMHCA Standards for the Practice of Clinical Mental Health Counseling (Revised 2023)
2. Skills
a. Demonstrate the ability to assess the various presentations of mental health disorders (e.g., mood disorders and cognitive and thought disorders, etc.) in older adults and their impact on functional status, morbidity, and mortality.
b. Demonstrate the ability to communicate respectfully and effectively with older adults and their families, accommodating for hearing, visual, and cognitive deficits.
c. Demonstrate the ability to communicate respectfully with older adults and their families, recognizing all multicultural considerations unique to older adults, particularly generational values and age-related abilities.
d. Demonstrate the ability to navigate and address issues associated with the emotional and physical challenges of the aging process, including how society responds to older adults using appropriate counseling strategies.
e. Demonstrate an ability to navigate the unique challenges related to confidentiality of patient information, informed consent, competence, guardianship, advance directives, wills, and elder abuse.
f. Demonstrate the ability to plan treatment, including a biopsychosocial conceptualization of predisposing, precipitating, and protective factors, mental status evaluation, diagnosis, and mental health assessment as it pertains to older adults.
g. Demonstrate familiarity with the diverse systems of care for patients and their families, and how to use and integrate these resources into a comprehensive treatment plan.
h. Demonstrate the ability to effectively interface with integrated health care professional and collateral sources, enlisting a multidisciplinary approach to the treatment of older adults.
AMHCA Standards for the Practice of Clinical Mental Health Counseling (2023)
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References
AMHCA (2023). AMHCA Standards for the Practice of Clinical Mental Health Counseling : Aging and Older Adults Counseling Standards and Competencies on page 36 Retrieved at: https://www.amhca.org/viewdocument/2023-amhca-standards-for-the-practice-of-clinical-Mental-Health-Counseling
Careers in Psychology (2019). Employment outlook & career guidance for geriatric
counselors. Retrieved at: https://careersinpsychology.org/employment-outlook-guidance-geriatric-counselors/
Centers for Disease Control and Prevention (CDC) and National Association of Chronic Disease Directors (NACDD) (2008). The state of mental health and aging in America. Retrieved at: https://www.cdc.gov/aging/publications/mental-health.html
Center for Mental Health and Aging (2024). Introducing the center for Mental Health and Aging. Retrieved at: https://www.mentalhealthandaging.com/introducing-the-center-for-mental-health-aging/
DeAngelis, T. (2022). By the numbers: Older adults report high levels of ageism. Monitor on Psychology, 53(6) p.88.
GeroCentral (2024) The Pikes Peak Geropsychology Competencies. Retrieved at: https://gerocentral.org/competencies/
Knight, B.G., Karel, M.J., Hinrichsen, G.A., Qualls, S.H., & Duffy, M. (2009). Pikes Peak Model for Training in Professional Geropsychology. American Psychologist, 64, 205-214.
Reframing Aging (2024). The story of reframing aging. Retrieved at: https://learning.reframingaging.org/
SeniorLiving.org (2018). The baby boomer generation. Retrieved at:
https://www.seniorliving.org/guides/baby-boomers/
WorkHealthLife. (2019). Baby boomers and mental health. Morneau Shepell Ltd.
Retrieved at: https://www.workhealthlife.com/ Article/.../07ca7901-d03b-402d-8579-c4b45fa718b9
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