History of Need for Geriatric
Mental Health Services
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Gerontology
A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Impact of COVID-19 on the Older Adults - Critical Issues to Be Addressed
Many Older Adults residents get admitted to nursing homes or assisted living facilities only when a crisis demonstrates the family can no longer provide care at home. This has become clearer during these COVID-19 times. It is commonly believed that the move into a nursing facility happens only when there is a breaking point and the person or persons at home can no longer provide the care required. Although families often feel guilty about “putting my mother (or father) in a nursing facility,” they know they do not have the skills, the physical and emotional capacity or the environment and equipment to provide the required care. Family members, for example, point to their lack of skill in ensuring the right medications are taken at the right time and actually swallowed, to the physical strength of those who need care putting the whole family at risk, to the stress of providing constant care, to the complicated machinery involved and to the difficulty in ensuring appropriate nutrition. The 24-hour demands are overwhelming even for those who have quit their paid work in order to provide this unpaid care. To suggest that families take the resident back home underestimates the complex, skilled care needs as well as the resources required while ignoring the crisis that got them there in the first place and may put both the resident and the family at risk for even more than infections (Armstrong et al, 2020).
Given that those over 80-year-old have a risk of death more than five times higher and those over 70 years old usually have at least one medical condition that qualifies them at risk of developing COVID-19 disease in a serious form. Research has shown that greater mortality risk in COVID-19 elderly patients with pre-existing cardiovascular comorbidities, hypertension, and diabetes mellitus (Moula et al., 2020). It was for these reasons that the United Nations identified four priorities for action when dealing with COVID-19 and the elderly:
1. Make sure that difficult nursing care decisions affecting the elderly are guided by commitment to dignity and health.
2. Maintaining social inclusion and solidarity during physical distance.
3. Full integration of older people in the socioeconomic and humanitarian response to COVID-19.
4. Expanding the participation of older people, sharing good practices, and capitalizing on knowledge and information (Grigorescu, 2020)
It is imperative that Older Adults are monitored closely during these COVID-19 times. They need to have their biological, mental health, pharmacological, social and environmental needs in a consistent and coordinated way (Baker & Clark, 2020). Their model includes these Key Points:
1. Social distancing and isolation will limit transmission but are likely to result in poor mental health for the older population
2. A systematic approach to mental health assessment that covers physical, psychological, pharmacological and social domains of health is needed to
identify subtle changes in mental health
3. Health professionals must understand the inter-relationship between each
domain and the impact a change in any one domain has on the other three
4. This bio-psycho-pharmaco-social model is one method of systematic
assessment of mental health in this population (Baker & Clark, 2020).
The experience in the USA since March 2020 has taught us that early detection and careful monitoring of frailty represent a neglected strategy in the management of older adults with COVID-19. From the geriatricians’ point of view, the enormous cultural background on frailty built in decades of hard research work needs to be mandatorily transferred to real-world clinical practice. A frailty-based tailored management of the older population, involving primary care and geriatric services, may help to prevent an overwhelming demand for beds and hospital resources and the risk of another unacceptable catastrophes (Maltese et al., 2020).
Researchers report that chronological age alone cannot be used to predict a geriatric patient’s performance in the face of COVID-19 because “having multiple chronic diseases and frailty is in many ways as or more important than chronological age” and that “an 80-year-old who is otherwise healthy and not frail might be more resilient in fighting off infection than a 60-year-old with many chronic conditions”. Notwithstanding the numerous defects normally associated with aging that result in greater vulnerability to infections, scientists have expressed optimism about measures to delay or minimize age-related immunological defects (de Castro-Hamoy & de Castro, 2020)
Older Adult patients who have entered palliative care due to their COVID-19 condition should hear and ‘feel’ from staff caring for them that they are not alone which suggests that, no matter what you may be going through in life, no matter how tough things are, there will always be someone caring by your side. It is important that palliative care staff help their patients and their families ti be able to feel their presence and compassion. This presence and support help patients and families with their own efforts of resilience and self-confidence, which, in turn, may give them a sense of purpose in life. In other words, such spiritual care is about enabling patients to have a purpose and meaning in life which is so needed in these COVID-19 times (Nyatanga, 2020).
Adults aged 60 years and over were worried about how COVID-19 had impacted their lives, and this affected their wellbeing, coupled with the loss of normal activities and consequent boredom. This highlight the importance of quality of life rather than years of life if people’s ‘twilight’ years are to be enjoyed rather than endured. Indeed, it may be a mistake to believe that everyone with frailty or multiple or serious health conditions wants their life extended or perhaps protected from an infection such as COVID-19 that may end their life, as evidenced by the growing support for assisted dying when individuals deem their life insufferable. This reality must be addressed when planning on treatment for our senior adults who have come down with COVID-19 (While, 2020)
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References for the COVID-19 Impact
Armstrong, H., Choiniere, J. Lowndes, R. & Struthers, J. (2020) Reimagining long-term residential care in the COVID-19 crisis. Toronto: Canadian Centre for Policy Alternatives
Baker, E. & Clark, L.L. (2020) Biosychopharmacosocial approach to assess impact of social distancing and isolation on mental health of older adults. British Journal of Community Nursing, 25(5), 231-238.
Burlacu, A., Mavrichi, I., Crisan-Dabija, R., Jugrin, D., Buju, S., Artene, B. & Covic, A. (2020). “Celebrating old age: An obsolete expression during the COVID-19 pandemic? Medical, social, psychological and religious consequences of home isolation and loneliness among the elderly. Archives of Medical Science DOI: https://doi.org/10.5114/aoms.2020.95955
de Castro-Hamoy, L. & de Castriom L.D. (2020). Age matters but it should not discriminate against the elderly in allocating scare resources in the context of COVID-19. Asian Bioethics Review 12, 331-340. https://doi.org/10.1007/s41649-020-00130-6
Grigorescu, A. C. (2020) United Nations political brief: Impact of COVID-19 on older people. Oncology-Hematolog 51,3.
Maltese, G., Corsonello, A., Di Rosa, M., Soraci, L., Vitale, C., Corica, F. & Lattanzio, F. (2020). Frailty and COVID-10: A systematic scoping review. Journal of Clinical Medicine, 9. 2106. doi:10.3390/jcm9072106
Moula, A.I., Micali, L.R., Matteucci, F., Luca, F., Rao, C.M., Parise, O., Parise, G., Gulizia, M.M & Gelsomino, S. (2020). Quatification of death risk in relation to sex, pre-existing cardiovascular diseases and risk factor in COVID-19 patients: Let’s take stock and see where we are. Journal of Clinical Medicine, 9, 2685. doi:10.3390/jcm9092685
Nyatanga, B. (2020). Enhancing spiritual harmony in palliative care. British Journal of Community Nursing, 25(8), 411.
While, A. (2020). COVID-19 and end of life. British Journal of Community Nursing, 25(8), 414.
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Baby Boomers Impact on Need for Increased Geriatric Mental Health Services
Following WWII, people around the world settled down to enjoy peace and prosperity and raise families. From 1946 to 1964, the largest generation in history was created: the Baby Boomers (WorkHealthLife, 2019). Because of their sheer numbers, the Boomers radically changed society at every stage of their lives and now that they’re in their 60s and early 70s they’re redefining old age and facing some significant mental health challenges. Over 25% of people over 55 experience some form of health issue but many go undiagnosed or untreated (especially men).
The most common mental health issues for people over 50 are:
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).
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).
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 (Careers in Psychology, 2019). 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).
A recent study found that One in two women and one in three men will develop dementia, stroke or parkinsonism during their life. These findings strengthen the call for prioritizing the focus on preventive interventions at population level which could substantially reduce the burden of common neurological diseases in the ageing Baby Boomer population (Licher et al., 2019).
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The stages of aging for Baby Boomers
Adapted from SeniorLiving.org, 2018
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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Need for Older Adults to Maintain Regular Physical Activity
In a study done in 2006 it was found that training primary-care providers in effective physical activity counseling is useful, but these providers were unlikely to spend much time on physical activity counseling; therefore, it found that it must be supplemented with other components of personalized counseling to ensure that seniors maintain the recommend levels of physical activity were maintained. (Morey, et al., 2006). This research resulted in an increase in “integrated medicine approach” with the elders to ensure that all aspects of their health maintenance were addressed.
Strength and balance training (SBT) has been identified as a tool to assist aging adults to maintain adequate health and physical function and that those that do not engage in such activities run the risk of lower cognitive abilities, suffer from a number of physical comorbidities, increase of drugs and risk for malnutrition (Aartolahit, Hartikalnen, Lonnroos & Hakkinen, 2014).
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Mental Health Issues of Older Adults
It has been recognized that older adults are less likely to report psychiatric symptoms and more likely to emphasize physical complaints (CDC, 2008). It is estimated that 20% of people age 55 years or older experience some type of mental health concern. The most common conditions include anxiety, severe cognitive impairment, and mood disorders (such as depression or bipolar disorder). Mental health issues are often implicated as a factor in cases of suicide. Older men have the highest suicide rate of any age group. Men aged 85 years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages (CDC, 2008).
Depression is the most prevalent mental health problem among older adults. It is associated with distress and suffering. It also can lead to impairments in physical, mental, and social functioning. The presence of depressive disorders often adversely affects the course and complicates the treatment of other chronic diseases. Older adults with depression visit the doctor and emergency room more often, use more medication, incur higher outpatient charges, and stay longer in the hospital (CDC, 2008). Although the rate of older adults with depressive symptoms tends to increase with age it has been pointed out that depression is not a normal part of growing older. Rather, in 80% of cases it is a treatable condition. Unfortunately, depressive disorders are a widely under-recognized condition and often are untreated or undertreated among older adults (CDC, 2008).
In 2015, it was demonstrated that those efficacious psychotherapies to address PTSD in younger and middle-age persons appear acceptable and efficacious with older adults (Dinnen, Simiola & Cook, 2015).
In the World Health Organization’s 2017 report on the mental health of older adults their findings included that globally the population is ageing rapidly in that between 2015 and 2050 the proportion of the world’s population over 60 years will nearly double from 12% to 22%. They also reported that mental and neurological disorders among older adults account for 6.6% of the total disability for this age group. Last their report was that 15% of adults aged 60 and over suffer from a mental disorder (WHO, 2015).
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Memory Decline, Dementia and Alzheimer’s Issues
In early research, it was found that patients with strokes who have epileptic seizures may be at increased risk of dementia and that they need to monitored closely from that point on (Cordonnier, Henon, Derambure, Pasquier & Leys, 2006). A contributing factor to elder adults developing late-life dementia was found to be chronic psychological distress thus supporting the need for increase mental health services which enable these seniors to cope with and lessen their distress (Wilson, Arnold, Scheider, Li & Bennett, 2007). It has been demonstrated that depression following an acute medical crises, such as stroke and traumatic brain injury (TBI), are relatively common and as a result for older adults can exacerbate or cause cognitive deficits (Jamora, Ruff & Connor, 2008).
There comes a point when family members are called in to make decisions about their elder family member’s care. It was found that family surrogates described their decision making as a process based in the families’ stories and as extensions of the elders’ identities. Four themes emerged from the analysis of the families’ decision-making: 1. acquisition of decision-making authority, 2. decision making for short-term or long-term time frames, 3. justifying the decisions and 4. advocacy for the elders (Elliott, Gessert & Peden-McAlpine, 2009). Later research demonstrated that caregivers who experience services of highly motivated health professionals in the care of their family members are highly satisfied even given the scarcity of resources available to them (Rodriquez, Paz & Sanchez, 2012),.
Research into the impact of strokes on the development of dementia in elders found that of the identified patients 10% had dementia before first the stroke, 10% developed new dementia soon after the first stroke, and more than a third had dementia after recurrent strokes. The strong association of post-stroke dementia with multiple strokes and the prognostic value of other stroke characteristics highlight the central causal role of stroke itself as opposed to the underlying vascular risk factors and, thus, the study concluded that optimum acute stroke care would hopefully result in secondary prevention in reducing the burden of dementia (Pendlebury & Rothwell, 2009).
It has been predicted that throughout the coming decades the baby boom generation is projected to add about 10 million to the total number of people with Alzheimer’s Disease (AD) in the United State whereas in 2013 it was estimated that 5.2 million had AD. (Alzheimer’s Association, 2013).
The Alzheimer’s Association in 2014 reported that sufficient strong evidence concluded that regular physical activity, management of cardiovascular risk factors (diabetes, obesity, smoking, and hypertension) reduce the risk of cognitive decline and may reduce the risk for dementia. They also concluded that a healthy diet and livelong learning/cognitive training may also reduce the risk of cognitive decline (Baumgart, Snyder, Carrillo, Fazio, Kim & Johns, 2015).
In comparing the costs of dementia in the United States between 2010 and 2015 it was found the costs informal care and direct costs of social care contributed equally to the total costs. They predicted that by 2018 the costs of dealing will dementia will rise to one trillion dollars which is directly related to the ever-increasing numbers of people with dementia and per person costs (Wimo, et al., 2017). In a comparable study it was predicted that the number of patients who will need care by clinicians with expertise in neurological conditions will continue to grow in coming decades (Neurological Disorders Collaborator Group, 2015).
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Suicide Rate Related to Older Adults
The suicide rate in the United States had reise by 24% from 1999 to 2014. The suicide rate for middle aged women, ages 45-64 jumped by 63 percent during this time frame. For middle aged men in the same age range the rate rose 43 percent which was the sharpest increase for males of any age according to the National Center for Health Statistics (Tavernise, 2016).
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Alcohol and Substance Abuse Treatment Needs
The prevalence of alcohol abuse or dependence among older adults was identified in 2004 with a plea to gain greater access to recovery services for these older adults as well as for those seniors with problem or hazardous drinking (which is estimated to be even more common among the elderly than alcohol dependence) (Oslin, 2004).
In 2006 it was found that depression and alcohol use were the most commonly cited co-occurring disorders in older adults. Dual diagnosis in older adults was associated with increased suicidality and greater inpatient and outpatient service utilization (Bartels, Blow, Van Citters & Brockman, 2006).
In 2014 it was recognized that patients entering methadone programs were more commonly presenting at ages well into their 50s, 60s, and 70s; and this phenomenon of high rates continues to grow (2014, Doukas)..It was found that majority of these individuals in treatment had presented with a number of significant comorbid medical conditions that progressed and eventually led to death. This aging cohort it was concluded must be approached with a modified treatment plan that focuses on management and promoting healthy aging, while attending to their maximum delay of illness, disease, and disability (2014, Doukas).
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Minority Related Issues in Treating Older Adults
The issue of how elder Hispanic and African American clients’ view the need for continued treatment for their mental health issues found that the following barriers exist: 1. Lack of desire and motivation for treatment; 2. Sense of shame and stigma and fear of mental health treatment; 3. Discomfort with therapy; 4. Perception of socioeconomic and cultural distances from while therapists and these clients; 5. Desire to maintain the role of a sick person; 6. Resistance from their adult children; and 7. Perception or expectation of a quick cure (Choi & Gonzalez, 2005).
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Caregivers for the Older Adults
Important Issues for the Baby Boomers who are the "Sandwich Generation"
Extensive research found that male and female caregivers have many experiences in common, but some research suggests that compared to females, male caregivers are even less likely to access services which must be recognized when dealing with a elder who is being cared for by a male family member or friend (2015, Greenwood & Smith).
In 2015, adherence to geriatric assessments and care plans for homebound frail older adults were high among medical staff involved but did decrease over time. Adherence to multidisciplinary consultations was initially poor but increased over time (Muntinga, Van Leeuwen, Schellevis, Nijpels & Jansen, 2015). The lack of fidelity to a chronic care model was emphasized as a result of this research.
In 2015, it was pointed out that the growing number of older adults and the increasing recognition and growth of integrated health teams are creating collaborative integrated teams, staffed with medical personnel and counselors which can provide comprehensive patient-centered care that addresses client issues from a biopsychosocial perspective (Goldsmith & Robinson Kurpius, 2015). However, ir was recognized that working with older adults on an integrated health team or in an interdisciplinary setting presents unique challenges and raises issues which all team members must be trained in(Goldsmith & Robinson Kurpius, 2015). These issues include working effectively in an integrated medical team, confronting diversity issues including ageism and understanding the ethical issues involved in such work.
Another major issues in working with older adults is the provision of adequate psychoeducation to the formal and informal caregivers of these adults. It was found in 2015 that there are low levels of participation in such psychoeducational programming due to such barriers as the need to escort to escort the care recipient to medical visits, cost of transportation, lack of time due to caregiving tasks or professional activity (Abreu, Silva, Costa & Abreu, 2015).
In a study of dementia-related anxiety among middle-aged female caregivers for family members with dementia it was found that these caregivers had a fear of losing their own identity involving six components: 1. Keenly feeling the effects of family member’s aging because of memory deficits. 2. Continuous comparison of the family member’s behavior with that of the caregivers. 3. Finding it painful to see a family member with dementia as he/she does not know how this will end. 4. Not knowing the conclusion of the disease process. 5. Reducing the risks of dementia. 6. Trying to change one’s lifestyle from what it used to be in the past (Kim, Kim & An, 2016). In 2016 researchers found that caregivers 75 years and older were very active responders and reported the rewards of their caring. The normality of caring was highlighted, with some suggesting that caring may be less challenging for older than for younger caregivers (Greenwood & Smith, 2016).
A 7-week psychoeducation program entitled “Living together with Dementia” was implemented was researched with families in Portugal and it proved to be an asset to family caregivers of people with dementia living at home (Sousa, et al., 2017). In Taiwan a 32 hour psychoeducational program for caregivers of patients with dementia was found to be productive in enhancing the psychological wellbeing of the caregivers (Hsu et. al., 2017).
In working with homebound elderly who had been diagnosed with Bipolar Disorder, it was found that caregivers were burdened by symptoms related to dementia in aging rather than the result of the Bipolar disorder in their family members (Santo, et al., 2017).
Family caregivers of people with dementia are their most important support in practical, personal, and economic terms. Caregivers are vital to maintaining the quality of life (QOL) of people with dementia. The factors related to the QOL of family caregivers of people with dementia were identified in a 2017 research project. The factors included: 1. The caregiver-patient relationship; 2. The characteristics of dementia displayed by the family member; 3. The caregiver’s health; 4. The caregiver’s emotional well-being; 5. The support the caregiver received; 6. The level of independence of the caregiver; 7. The caregiver’s self-efficacy 8. The demands of providing care to the family member; 9. The caregiver’s independence and 10 The future perspective of the caregiver (Farina et. al., 2017). In 2018 a study demonstrated the effectiveness of a 2-day intervention program improved the psychological health of caregivers of individuals with Dementia. The intervention included training in self-care and improving communications between the caregivers and the aging adults in their care (Spalding-Wilson, Guzman-Velez, Angelica, Wiggs, Savransky & Tranel, 2018).
The Inventory of Overburden in Alzheimer’s Patients Family Caregivers was able to identify six factors: 1. Reaction to diagnosis; 2. Physical health of the Caregiver: 3. Psychological symptomatology of the caretaker; 4. Behavioral symptomatology of the patient; 5. Knowledge of the illness by the caretaker, and 6. Level of dependence of the famlly member with Alzheimer’s (Perez-Fuentes, Linares, Fernandez & Jurado, 2017).
Psychological abuse of elderly is a major barrier in providing adequate care to older adults. The consequences of psychological abuse is frequent and prolonged hospitalizations, and associated with high costs of medical services. This abuse leads to patient’s lack of self-confidence which, in time, may lead to social isolation, somatization, anxiety, depression, and suicide attempts. For this reason is must be identified early to insure optimal care for older adult patients (Ilie, et al., 2017).
There were six risk factors identified for caregivers of older homebound adults with dementia. They are:
1. Stress: caring for a person with dementia is considered stressful by the caregivers
2. Difficult and challenging: meaning it is difficult for the caregivers to see the people they care declining and not being able to stop it or working with people who are child-like when they themselves have had their own children grow and leave their care
3. Demanding: This work can be demanding and multiple demands of these aging adults can be overwhelming
4. Frustration: People with dementia display frustrating emotions which cannot be tempered or addressed such as anger, denial and lack of rational thinking
5. Lack of social support: This is especially a problem for caregivers who are family members of the older adult with dementia because they experience a lack of support from their other family members to pitch in when they need help
6. Negative feelings: Sadness and anger are major negative emotions expressed by family caregivers (Bekher & Avery, 2018).
Social exclusion of informal caregivers of older adults with dementia or severe mental health disorders negatively impacts the quality of their lives and as a result they need clinical intervention to help strengthen their commitment to care for their family members (Greenwood, Mezey & Smith, 2018).
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Mental Health Professionals’ Perspectives on working with Older Adults
In 1995, the American Counseling Association announced standards for counselors working with older adults which were then incorporated into a specialty certification by the National Board of Certified Counselors (NBCC) (Meyer, 1995). Here are their standards which badly need updating to adequately address the needs of our current aging adult population:
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A. Minimum Essential Gerontological Competencies for All Counselors (Generic) (Meyer, 1995)
1. Exhibits positive, wellness-enhancing attitudes toward older persons, including respect for the intellectual, emotional, social, vocational, physical, and spiritual needs of older individuals and the older population as a whole.
2. Exhibits sensitivity to sensory and physical limitations of older persons through appropriate environmental modifications to facilitate helping relationships.
3. Demonstrates knowledge of the unique considerations in establishing and maintaining helping relationships with older persons.
4. Demonstrates knowledge of human development for older persons, including major psychological theories of aging, physiological aspects of "normal" aging, and dysfunctional behaviors of older persons.
5. Demonstrates knowledge of social and cultural foundations for older persons, including common positive and negative societal attitudes, major causes of stress, needs of family caregivers, and the implications of major demographic characteristics of the older population (e.g., numbers of women, widows, increasing numbers of
older minorities).
6. Demonstrates knowledge of special considerations and techniques for group work with older persons.
7. Demonstrates knowledge of lifestyle and career development concerns of older persons, including the effects of age-related physical, psychological, and social changes on vocational development, factors affecting the retirement transition, and alternative careers and lifestyles for later life.
8. Demonstrates knowledge of the unique aspects of appraisal with older persons, including psychological, social, and physical factors that may affect assessment, and ethical implications of using assessment techniques.
9. Demonstrates knowledge of sources of literature reporting research about older persons and ethical issues in research with older participants.
10. Demonstrates knowledge of formal and informal referral networks for helping older persons and ethical behavior in working with other professionals to assist older persons.
B. Minimum Essential Competencies for Gerontological Counseling
Specialists (Specialty)
1. Demonstrates and actively advocates for positive, respectful, wellness-enhancing attitudes toward older persons and a concern for empowerment of persons throughout the life span.
2. Demonstrates skill in applying extensive knowledge of human development for older persons, including major theories of aging, the relationship between physical and mental health and aging, the difference between normal and pathological aging processes, gender related developmental differences, and coping skills for life transitions and loss.
3. Demonstrates skill in applying extensive knowledge of social and cultural foundations for older persons, including characteristics and needs of older minority subgroups, factors affecting substance and medication misuse and abuse, recognition and treatment of elder abuse, and knowledge of social service programs.
4. Demonstrates the ability to function in the multiple roles required to facilitate helping relationships with older persons (e.g., advocate, family consultant) and to mobilize available resources for functioning effectively in each role.
5. Demonstrates skill in recruiting, selecting, planning, and implementing groups with older persons.
6. Demonstrates skill in applying extensive knowledge of career and lifestyle options for older persons, age-related assets and barriers to effective choices, and resources for maximizing exploration of career and lifestyle options.
7. Demonstrates skill in appraisal of older persons, including identifying characteristics of suitable appraisal instruments and techniques and in using assessment results in developing treatment plans.
8. Demonstrates skill in applying extensive knowledge of current research related to older persons and the implications of research findings for helping relationships.
9. Demonstrates skill in applying extensive knowledge of the intellectual, physical, social, emotional, vocational, and spiritual needs of older persons and strategies for helping to meet those needs.
10. Demonstrates skill in applying appropriate intervention techniques, in collaboration with medical and other care providers, for physical and mental impairments common to older persons, such as acute, chronic, and terminal illness, depression, suicide, and organic brain syndromes.
11. Demonstrates extensive knowledge of the formal and informal aging networks, public policy, and legislation affecting older persons, and knowledge of a continuum of care that will allow older persons to maintain their highest level of independence.
12. Demonstrates skill in applying appropriate intervention techniques for situational and developmental crises commonly experienced by older persons, such as bereavement, isolation, divorce, relocation, sexual concerns, illness, transportation, crime, abuse, and relationships with adult children and caregivers.
13. Demonstrates skill in the use of a wide variety of specialized therapies to assist older persons in coping with both developmental and nonnormative issues, such as creative arts therapies, pet therapy, peer counseling, and family counseling.
14. Demonstrates skill in applying extensive knowledge of ethical issues in counseling older persons, their families, and care providers.
15. Demonstrates the ability to act as a consultant to individuals and organizations on issues related to older persons and their families.
16. Demonstrates skill in program development for the older population, including needs assessment, program planning, implementation, and evaluation.
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In 1999, after an extensive survey of training programs regarding the availability of courses, research and clinical training experiences with working with seniors, the social work profession appeared to be preparing its students best for future work with older adults (Ryan & Agresti, 1999). This was a concern given that at the time it was estimated that by 2020 due to the persistent growth in the numbers of older adults in need of services there would be a lack of sufficiently trained mental to meet their needs.
To improve the Medicare care offered for older Americans, there has been a call to utilize the expertise of geriatricians to address the needs of most complex patients especially in terms of prescribing outpatient medications (Nusbaum, 2005).
In reviewing the future needs of the aging Baby Boomers (born between 1946 and 1967), a review was made of the economic and demographic data in 2002 with a simulation of projected socioeconomic and demographic patterns in the year 2030. The results of this study found that there would be real challenges especially in providing for long-term care services for this aging population which numbers close to 61 million people (Knickman & Snell, 2002). This study concluded the following:
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The real challenges of caring for the elderly in 2030 will involve:
(1) Making sure society develops payment and insurance systems for long-term care that work better than existing ones,
(2) taking advantage of advances in medicine and behavioral health to keep the elderly as healthy and active as possible,
(3) changing the way society organizes community services so that care is more accessible, and
(4) altering the cultural view of aging to make sure all ages are integrated into the fabric of community life (Knickman & Snell, 2002).
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For psychiatrists working with geriatric patients there are common themes that they were encouraged to address when conducting geriatric psychotherapy which include:
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1. Restoration of a positive self-concept and self-esteem;
2. Dealing with loss including spouses, friends, relatives, roles, functions and independence with the potential of survivor’s guilt in the mix;
3. Dealing with aging, illness and possible dependence;
4. Dealing with the reality of impending death;
5. Transference when a patient experiences the therapist as a significant figure from the past with whom a highly significant and developmentally important relationship had existed or
6.Countertransference when the therapist experiences anxiety provoking feelings due to either the patient’s dementing illness or physical problems or apparent dependency or helplessness (Atiq, 2006).
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In 2021 AMHCA updated its standards and competencies list to include Aging and Older Adults as follows
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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.
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 (Revised 2021)
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As you can see these standards also need much updating which we will be addressing in this Training Resource.
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Online Resources when Working with Older Adults
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