Older Adults

NU 615
Objectives
• Describe national demographic and health trends of older adults.
• Discuss the physiological, psychological and developmental needs of older adults.
• Describe the insurance landscape and settings for older adults with psychiatric problems.
• Examine the implications for psychiatric-mental health nurse practitioners when caring
for older adults.
Older Adults
• Growth in number and proportion of older adults living in the United States; projected to
reach 30% of population by 2060
• Globally
• Number of adults aged 65 years or older expected to reach 1.5 billion by 2050
(tripled from 2010)
• Increased demands on public health system, medical and social services, and health care
delivery
• Adults over 65 years of age use the most significant number of medications of any
age group; comprise 25 percent of all prescriptions.
• Disparities in health status among racial and ethnic minorities; will continue to
increase
• Older population projected to be comprised of 42% of persons who identify as a
racial or ethnic minority in 2050, up from 20% in 2010
Misconceptions
• Depression and loneliness are normal
• Sleep needs decrease with age
• Older adults can’t learn new things
• (none of the above are true)
• Poor memory is expected with increased age
https://www.nia.nih.gov/health/10-myths-about-aging
- Nurse practitioners must identify and build on an older person’s strengths as opposed to
focusing on their difficulties
- Many age-related illnesses develop insidiously and gradually progress over the years.
Biologic Changes of Aging
• Neuronal degeneration in central nervous system, primarily in superior temporal
precentral and inferior temporal gyri
• Impaired T-cell response to antigen
• Increase in function of autoimmune bodies
• Increased susceptibility to infection and neoplasia
• Reduction in lean muscle mass and muscle strength;
• Increase in body fat
• Decreased glomerular filtration rate and renal blood flow
• Takes longer to learn new material
• Psychomotor speed declines
• Tasks requiring shifting attentions performed with difficulty
• Recognition of right answer on multiple-choice tests remains intact
• Norepinephrine decreases in central nervous system
 • Increased monoamine oxidase and serotonin in brain
• Altered absorption from GI tract
•
Psychological Aspects of Older Adulthood
• Social Activity
• Ageism
• Transference
• Countertransference
• Socioeconomics
• Retirement
• Sexual activity
• Long-term care
•
Developmental Tasks of Older Adulthood Ego Integrity vs Despair (beyond narcissism, move
into intimacy and generativity)
• To maintain the body image and physical integrity
• To conduct the life review
• To maintain sexual interests and activities
• To deal with the death of significant loved ones
• To accept the implications of retirement
• To accept the genetically programmed failure of organ systems
• To divest oneself of the attachment to possessions
• To accept changes in the relationship with grandchildren

- Erikson proposed that successful resolution of this crisis would be characterized by a

sense of having lived one’s life well, whereas a less successful resolution would be
characterized by feeling that life was too short, that one did not choose wisely, and
bitterness that one will not have a chance to live life over.

Common Health Conditions Among Older Adults

• Arthritis
• Cardiovascular disease
• Depression
• Diabetes
• Hearing and visual impairment
• Obesity
• Osteoporosis
• Deformity or orthopedic impairment

Evaluation of Older Adults

• Functioning: Capacity to maintain independence and to perform the activities of daily
life, which include toileting, preparing meals, dressing, grooming, and eating.
• Cognitive assessment:
• Mini-Mental State Examination (MMSE)- assesses orientation, attention,
calculation, immediate and short-term recall, language, and the ability to follow
simple commands. (7-8 minutes)
 • Montreal Cognitive Assessment (MoCA)- assesses orientation, attention,
memory, executive function, language, abstraction, clock drawing and animal
naming (10-12 minutes)
• Mood: The Geriatric Depression Scale is a useful screening instrument that excludes
somatic complaints from its list of items.
• Thought: Hallucinations and illusions by older adults can be transitory phenomena
resulting from decreased sensory acuity.
• Brain tumors and focal pathology may cause hallucinations and perceptive
impairments
• Types of agnosia include denial of illness (anosognosia), denial of a body part
(atopognosia), and inability to recognize objects (visual agnosia) or faces
(prosopagnosia).
Mental Health Problems in Older Adults
• Most common: depressive disorders, cognitive disorders, phobias, and alcohol use
disorders.
• Risk factors include loss of social roles, loss of autonomy, death, declining health,
increased isolation, financial constraints, and decreased cognitive functioning
• Depression may be under-recognized in older adults
• Accompanied by physical symptoms and cognitive changes
• The incidence of suicide among older persons is high and is highest for older white men.
Pharmacological Considerations for Older Adults
An adage in geriatric medicine regarding the use of drugs is: Start low, go slow.

• Alterations in dosages are required

• Renal disease is associated with a decreased renal clearance of drugs; liver disease
results in a decreased ability to metabolize drugs; cardiovascular disease and
reduced cardiac output can affect both renal and hepatic drug clearance.
• Lean body mass decreases and fat increases
• Many lipid-soluble psychotropic drugs are distributed more widely in fat
than in lean tissue resulting in prolonged action
• Increased risk of orthostatic hypotension due to reduced functioning of blood
pressure–regulating mechanisms
Psychotherapy for Older Adults
• Insight-oriented psychotherapy, supportive psychotherapy, cognitive therapy, group
therapy, and family therapy—should be available.
• Therapists must be more active, supportive, and flexible.
• Older persons usually seek therapy for a therapist’s unqualified and unlimited support,
reassurance, and approval.
Settings for Older Adults
• Inpatient
• Acute and subacute units
• Nursing homes
• Skilled nursing facilities (including memory care)
• Intermediate care; assisted living
• Continuing care retirement communities
• Outpatient
 • Veterans care
• Hospice and palliative care
Insurance
• Medicare provides both hospital and medical insurance for those over age 65.
• Part A: inpatient hospitalizations; also pays some of the costs of skilled nursing
facilities and health care at home.
• Part B: outpatient care including preventive services, diagnostics and labs
services, medical equipment, mental health care, home health care not covered by
Part A
• Part C: Medicare Advantage Plans
• Part D: Medicare Drug coverage
• Some services are not covered or only partially covered (LTC)
• Services not covered by Medicare: dental, vision and hearing
• Medigap is private insurance that supplements Traditional (Original) Medicare
• Defined as “Medicare Supplement Insurance”
• Pays for copayments, coinsurance, and deductibles
• Mental health and substance use services covered by Medicare
• Outpatient individual and group psychotherapy
• Family counseling
• Psychiatric evaluation
• Medication management
• Medications that are injectables
• Diagnostic tests
• Partial hospitalization
• Inpatient hospitalization (Medicare Part A)
• Medicare Advantage Plans (Part C)
• Private companies that provide all care including Part A and B
• Not the same as Medigap
• Several types of plans
• Health Maintenance Organization
• Preferred Provider Organization
• Private Fee for Service
• Special Needs Plans
Expansion of MH Services for Medicare Beneficiaries
• Lower cost sharing for outpatient services
• More consistent access to medication
• Telehealth coverage
• Integrated care billing
https://www.commonwealthfund.org/publications/explainer/2023/mar/medicare-mental-health-
coverage-included-changed-gaps-remain

Gaps in Mental Health Services for Medicare Beneficiaries

• Inpatient day limits
• Limited mental health provider network
• Lack of coverage and Medicare Advantage plans for serious mental illness
https://www.commonwealthfund.org/publications/explainer/2023/mar/medicare-mental-health-
coverage-included-changed-gaps-remain

Shift in Care
• Prescribing medications: must consider changes in physiology, polypharmacy and drug-
drug interactions
• Therapy focuses on adapting to recurrent and diverse losses (e.g., the deaths of friends
and loved ones), the need to assume new roles (e.g., the adjustment to retirement and the
disengagement from previously defined roles), and the need to accept mortality.
• Care coordination and referral
• Collaborating with family members
References
• Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan and Sadock’s Synopsis of
Psychiatry (12th Edition). Philadelphia, PA: Wolters Kluwer.
• Centers for Medicaid and Medicare Services (2023). Medicare.Gov
https://www.medicare.gov/what-medicare-covers.
• Centers for Medicaid and Medicare Services (2023). Medicare.Gov
https://www.medicare.gov/Pubs/pdf/10184-Medicare-and-Your-Mental-Health-
Benefits.pdf.
• Commonwealth Fund (March 2023). https: //
www.commonwealthfund.org/publications/explainer/2023/mar/medicare-mental-health-
coverage-included-changed-gaps-remain