Aging and Mental Health

Mark Ebony Sumalinog, RN MSN

• Many people believe that loss of mental
functioning, “senility”, or mental incompetence is
normal part of old age

• This misconception is widely accepted that when

an older adult demonstrates pathologic signs, it is
considered normal no attempt is made to
intervene

• Nurses can play a significant role in ensuring that

myths and realities of mental health in old age
are understood
• Cognitive function in later life is HIGHLY
INDIVIDUALIZED based on personal resources,
health status and the unique experience of
the individual’s life

• The incidence of mental illness is higher

among old than among the young

• A significant number of older adults in the

community and in nursing homes have
symptoms of serious mental health problems
• 10 % of the older population has a problem
with alcoholism

• Rate of completed suicide among older

persons continues to be the highest of any age
group in the United States; nearly ¼ are aged
65 years and older (Lobel, 2005)

• Depression increases in prevalence and

intensity with age
• Multiple losses, altered sensory function, and
alterations, discomforts and demands
associated with illness set the stage for a
variety of health problems
 Promoting Mental Health in Older
Adults
• Mental health in old age implies A SATISFACTION
AND INTEREST IN LIFE

• This can be displayed in a variety of ways, ranging

from silent reflection to zealous activity

• Note: the quiet individual does not necessarily

have less mental capacity or mental health than
the person who is actively involved in a
community program
• GOOD MENTAL HEALTH practices throughout
an individual’s lifetime promote good mental
health in later life

• To preserve mental health, people need to

maintain the activities and interests that they
find satisfying

• They need opportunities to sense their value

as a member of the society and to have their
self worth reinforced
• Security through adequate income, safe
housing, the means to meet basic human
needs and support and assistance through
stressful situations will promote mental
health.

• Connection with others is also an aspect of

mental health

• Importance of optimum physical health

Principles in the care of persons with mental
health problems:

A. Strengthen the individual’s capacity to

manage the conditions
B. Eliminate or minimize the limitation imposed
by the condition
C. Act for or do for the individual only when
absolutely necessary
• Strengthen the individual’s capacity to
manage the conditions

Fostering improvement of physical health,

good nutrition, increased knowledge,
meaningful activity, stress management,
income supplements, and socialization
• Eliminate or minimize the limitation imposed
by the condition:

providing consistency of care, not fostering

hallucinations, reality orientation, correction
of physical problems, and modifying the
environment to compensate for deficits
• Act for or do for the individual only when
absolutely necessary

Selecting an adequate diet, assisting with

bathing, administering medications, managing
finances, and coordinating activities for the
patient
Problems that challenges an older adult’s
emotional homeostasis:
A. Illness: coping, related self-care demands,
pain, altered function or body image
B. Death: friends, family, significant support
person
C. Retirement: loss of status, role, income,
sense of purpose
D. Increased vulnerability: crime, illness,
disability, abuse
E. Social Isolation: lack of transportation, funds,
health, friends
F. Sensory deficits: decrease in or loss of
function of hearing, vision, taste, smell and
touch
G. Greater awareness of own mortality:
increased number of deaths among peers
H. Increased risk of institutionalization,
dependency: loss of self-care capabilities to
varying degrees
 Assessment Guide
General Observation:
• Grooming and dressing: appropriate?
• Posture: stooped or fearful?
• Movement: tongue rolling, twitching, tremors,
and hand wringing? Are movements hyper- or
hypoactive?
• Facial expression: masklike or overly dramatic? In
pain? Fear? Anger?
• Level of consciousness
 Assessment Guide
Interview:
• How do you feel about yourself?
• Do you have any friends? How do you get
along with people?
• Do you feel that anyone is trying to harm you?
Who? Why?
• Are you moody? Do you quickly go from
laughing to crying or from being happy to sad?
 Assessment Guide
Interview:
• Do you have trouble falling asleep or staying
asleep? How much sleep do you get? Do you
use drugs or alcohol to become sleepy?
• How is your appetite? How does you appetite
and eating pattern change when you are sad?
• Do you ever have feelings of being nervous,
such as palpitations, hyperventilating, and
restlessness?
 Assessment Guide
Interview:
• Are there any particular problems in your life or
anything that you are concerned about now?
• Do you hear or see things that other people do
not? If yes, how do you feel about them?
• Does life bring you pleasure? Do you look forward
to each day?
• Have you ever taught about suicide? If so, what
were those ideas like? How would you do it?
 Assessment Guide
Interview:
• Do you feel you are losing any of your mental
abilities?
• Have you ever been hospitalized or had
treatment for mental problems? Has any
member of your family?
 Assessment Guide
Cognitive Testing:
• MMSE (Folstein, 1975)
• General Health Questionnaire (Goldberg, 1972)
• OARS (Duke University, 1978)
• Short Portable Mental Status Questionnaire
(Pfeiffer, 1975)
• Philadelphia Geriatric Center Mental Status
Questionnaire (Fishback, 1977)
• Geriatric Depression Scale or Zung Self-Rating
Depression Scale (Zung, 1965)
 Assessment Guide
Even without those tools, the nurse can assess
basic cognitive function in the following ways:
a. Orientation
b. Memory and Retention
c. Three stage commands
d. Judgment (basic problem solving and
reasoning)
e. Calculation
 Assessment Guide
Note: Consider unique experiences, educational
level, and cultural background of the patient,
as well as sensory deficits, health problems,
and stress associated with being examined.

Discontinue if patient is in catastrophic reaction

(react with tears, anger, or withdrawal).
 Assessment Guide
• Physical Examination
• Review of Medications
• Series of Laboratory Tests: CBC, serum
electrolytes, serologic test for syphilis, BUN,
bilirubin, blood vitamin level, ESR, urinalysis,
CSF testing, EEG, CT scan, MRI, PET scan
SELECTED MENTAL HEALTH
CONDITIONS
DEPRESSION
ANXIETY
ALCOHOL ABUSE
HYPOCHONDRIASIS
PARANOIA
 Depression
• Most frequent problem that psychiatrist treat
in older adults

Prevalence:
• 15 to 25 % of community older adults
• 25 % of older adults in long term care facility
• 20 to 30 % in nursing homes
Causes:
• Independence of one’s children
• The reality of retirement
• Significant changes or losses of roles
• Reduced income
• Restricted satisfying leisure activity
• Limited basic needs
• Decreasing efficiency of the body
• Changing self-image
• Death of family and loved ones
• Reinforcing the reality of shrinking life span
• Ageism by the community: elderly are worthless
DRUGS THAT CAN CAUSE DEPRESSION
• Anti-hypertensives and Cardiac Drugs: Beta
blockers, digoxin, procainamide, guanethidine,
clonidine, reserpine, methyldopa, spironolactone
• Hormones: corticotropin, corticosteroids,
estrogen
• CNS depressants, anti-anxiety agents,
psychotropics: alcohol, haloperidol, flurazepam,
barbiturates, benzodiazepines
• Others: cimetidine, L-dopa, ranitidine,
asparaginase, tamoxifen
 Signs and symptoms
• COMPLEX SYNDROME • Remorse
• Insomnia • Hopelessness
• Fatigue • Helplessness
• Anorexia • Feeling of being a burden
• Weight loss • Problems with
• Constipation relationships
• Decreased interest in sex • Problems with social
• Guilt interactions
• Apathy • Changes in sleep and
psychomotor activity
pattern
 Signs and symptoms
• Hygienic practices • Careful not to confuse
neglected depression with
• Physical complaints of dementia
– Headache
– Indigestion
• Altered cognition
• Malnutrition
 Treatment

• Psychotherapy
• Antidepressants
• Electroconvulsive therapy (if unresponsive with
other treatments)
• St. John’s Wort (effective on mild depression)
– Should not be used alongside with antidepressants
because it cause photosensitivity
• Acupressure, acupuncture, guided imagery an
light therapy (in conjunction with psychotherapy)
• Proper nutrition, regular exercise (positive mood)
 Antidepressants
• Selective Serotonin Reuptake Inhibitor
Fluoxetine (Prozac), Sertraline (Zoloft)

• Cyclic Compounds
Amoxapine (Asendin), Doxepin HCl (Adapin, Sinequan),
Nortriptypline HCl (Aventyl)

• Monoamine Oxidase Inhibitors

Phenelzine (Nardil)
 Nursing Guidelines in Giving
Antidepressants
• Dosage for older adults should begin at about a
half that recommended for general adult
population

• Sedation commonly occurs during the initial few

days of treatment; take fall risk precautions

• At least one month of therapy before

therapeutic effects will be noted; advise and
support the patient during this period
• Bedtime administration is preferable with
antidepressants that produce a sedative effect

• Prepare patients for side effects: dry mouth,

diaphoresis, constipation, urinary retention,
indigestion, hypotension, blurred vision,
drowsiness, increased appetite, weight gain,
photosensitivity, and fluctuating blood glucose

• Be alert to anticholinergic symptoms,

particularly when cyclic compounds are used.
• Ensure that older adults and their caregivers
understand dosage, intended effects, and
adverse reactions to the drugs.

• Instruct about drug to drug interaction.

ex. Antidepressants can increase the effects of anti-coagulants,
atropine-like drugs, antihistamine, sedatives, tranquilizers, narcotics
and levodopa

ex. Antidepressants can decrease the effects of clonidine,

phenytoin, and some hypertensives

ex. Alcohol and thiazide diuretics can increase the effects of

antideppresants
NURSING CONSIDERATIONS IN CARING FOR
DEPRESSED PATIENTS

• Help the patient develop a positive self-

concept. It must be emphasized that, although the
situation may be bad, the person is not.
Opportunities for success, regardless of how major
or minor, should be provided, and new goals should
be formed
• Encourage the expression of feelings. Anger,
guilt, frustrations, and other feelings should be
vented. Nurses should afford time to listen and guide
patients through these feelings. In addition to
verbalization, feelings can be expressed through
writing.

• Avoid minimizing feelings. Statements such as

“Don’t worry, things will get better” or “Don’t talk
that way, you have a lot to be thankful for” offer little
benefit to depressed persons.
• Ensure that physical needs are met. Good
nutrition, activity, sleep, and regular bowel
movements are among the factors that enhance a
healthy physical state, which in turn strengthen the
patient’s capacity to work through depression.
Physical problems must be aggressively addressed.

• Offer hope. While being realistic regarding the

individual situation, nurse can, by words and deeds,
convey their belief that the future will have meaning
and that the patient’s life is of value.
• All suicide threats from older persons should be
taken seriously (different ways to show desire to
die)
– Engaging in activities that oppose a therapeutic need
or threaten a medical problem (ex. Ignoring dietary
restrictions)
– Walking through a dangerous area
– Driving while intoxicates
– Subjecting oneself to other risks

Mgmt: close observation, careful protection and

prompt therapy, safe environment, nurses convey
willingness to listen
 Anxiety
• Causes: adjustment to physical, emotional and
socioeconomic limitations in old age

• Manifestations: somatic complaints, rigidity in

thinking and behavior, insomnia, fatigue,
hostility, restlessness, chain smoking, pacing,
fantasizing, confusion and increased
dependency
• An increase in blood pressure, pulse,
respirations, psychomotor activity and
frequency in voiding

• Appetite may increase or decrease

• Handles jewelry, clothing and utensils

excessively

• Becomes intensively involved with minor task (ex.

Folding laundry)

• Difficulty concentrating on the activity at hand

• Nurses should probe into the history for
recent changes and stresses
• Review for consumption of caffeine, alcohol,
nicotine, and OTC drugs
• Biofeedback, guided imagery and relaxation
therapy
• Anxious people need their lives to be
simplified and stable
• Environmental stimuli must be controlled
• Allow adequate time for conversation,
procedures and activities
• Encourage and respect the patient’s decisions
over matters affecting his or her life
• Prepare the individual for all anticipated
activities
• Provide thorough, honest and basic
explanations
• Control the number and variety of persons
with whom the patient must interact
(consistency)
• Adhere to routines
• Keep use of familiar objects
• Reduce noise, use soft lights, maintain a stable
room temperature
 Alcoholism/ Alcohol Abuse
• It goes unnoticed, sometimes because it
mimics symptoms of common geriatric
conditions

• It can seriously threaten the physical,

emotional, and social health of older persons

• Abuse of, dependency on, or addiction to

alcohol
• Older adults who drink alcohol and who take
medications increase their risk of adverse drug
reactions/ consequences

• They are at risk of falls, reduced cognitive

function, abuse, and self-neglect

• Nurse help older adults seek appropriate and

proper treatment for this matter
• Most older adults who are alcoholics are chronic
alcohol abusers who have used it heavily
throughout their lives

• Significant number of chronic abusers die before

reaching old age, contributing to decreased
incidence of alcoholism with age

• The other type of older alcoholics is the one who

begins abusing alcohol in late life because of
situational factors (ex. Retirement, widowhood,
or poor health status)
• Alcohol abusers come in many forms- do not
stereotype (ex. Retired professional drinking in
a country club versus a widow who begins
sipping brandy in the midmorning)
 POSSIBLE INDICATIONS OF ALCOHOL
ABUSE
• Drinking alcohol to calm • Anxiety
nerves or improved mood • Irritability
• Gulping or rapidly • Depression
consuming alcoholic • Mood swings
beverages
• Memory blackout • Lack of motivation or
energy
• Malnutrition • Injuries, falls
• Confusion • Insomnia
• Social isolation and • Gastrointestinal distress
withdrawal
• Disrupted relationships • Clumsiness
• Arrests for minor offenses
• Alcohol abuse can be manifested in a variety of
ways, some of which may be subtle or east to
confuse with other disorders

• Symptoms can develop secondary to

complications from alcoholism, such as cirrhosis,
hepatitis, and chronic infection (related to
suppressed immune system)

• Tools: Short Michigan Alcohol Screening Test-

Geriatric Version (Blow et al, 1992) & Alcohol Use
Disorders Identification Test (Audit) (Babor et al,
2001)
DEFINITIVE DIAGNOSIS OF ALCOHOLISM/ CRITERIA

• Drinks a fifth of whiskey a day or its equivalent in

wine or beer (for a 180-lb person)
• Alcoholic blackouts
• Blood alcohol level greater than 150 mg/ 100 ml
• Withdrawal syndrome: hallucinations,
convulsions, gross tremors, delirium tremens
• Continued drinking despite medical advice or
problems caused by drinking
COMPLICATIONS:
• Magnesium deficiencies
• Gastritis
• Pancreatitis
• Polyneuropathy
• Cardiac disorders (hypertension, irregular
heartbeat, and heart failure due to
cardiomyopathy)
• Cognition can be impaired by a loss of brain
cells and enlargement of ventricles
MANAGEMENT:
• Long term goal is sobriety (only if the patient
acknowledges the problem and takes
responsibility for doing something about it)

• Family involvement (Support system:

Alcoholic Anonymous)- encouragement

• Benzodiazepines (detoxification)- given in

lower doses (toxicity may occur if dosage is
similar to that of alcoholic younger adults)
 Paranoia
Paranoid state occurs because:
• Sensory losses (misperceived environment)
• Illness, disability, living alone, and a limited
budget promote insecurity
• Ageism within society sends a message of the
undesirability of the old
• Older people are frequently victims of crime
and unscrupulous behavior
• Hyperthyroidism can cause paranoia
• It can also be an adverse effect of medications

Management:
• Importance of a good physical evaluation and
history when psychiatric symptoms are
present
• Reduce insecurity and misperception:
– Corrective lenses, hearing aids, supplemental
income, new housing, and a stable environment
• Medication review
• Psychotherapy
• Nurses should ensure that these patients do not
become withdrawn from the rest of the world
because of self-imposed isolation
• Nutritional status (they think their food is poisoned)
• Sleep deprivation (suspicion that a stranger is in the
house)
• Health problems may not be diagnosed (thinks that the
doctor is an enemy)
• DO NOT SUPPORT DELUSIONS!!!
• Honest basic explanations and approaches to dealing
with paranoid misperceptions are beneficial
 Hypochondriasis
• Commonly associated with depression

• An attention-getting mechanism

• Health professionals reinforce this behavior by

reacting to physical complaints promptly but
not reinforcing periods of good function and
health
• Give undivided attention when that person
expresses physical discomfort

• Some find it an effective way to control

spouse and children

• Some use it as means of socialization; they

count on their peers having similar ailments
(common ground for conversation)
• Complains must be evaluated for their validity
before assuming that they are part of
Hypochondriasis

• It is beneficial to help these people find

alternatives to their obsession with their bodily
functions

• Spending time in non-illness-related

conversation can demonstrate that one can
receive attention without resorting to physical
complaints
• Family members need to understand the
dynamics of this problem so that they can
reinforce positive behaviors and not be
manipulated

• NOTE: Health care professionals may promote

hypochondriac behaviors by investing more
time and interest reviewing the complaints of
the older person than in discussing interests
and normal life activities
 Nursing Considerations for
Mental Health Conditions
Monitoring Medications
• Watch for profound adverse effects on older
adults
– Anorexia, constipation, falls, incontinence,
anemia, lethargy, sleep disturbances and
confusion
• Lowest possible dosage should be used, and
any reactions should be observed closely
• Insert table
 Nursing Considerations for
Mental Health Conditions
Promoting a Positive Self-Concept
• All people need to feel that their lives have
had meaning and that there is hope
• Sense of meaninglessness and hopelessness is
a threat to mental health
• Nurses should take sincere interest in the lives
and accomplishments of their older patients
• Struggles and accomplishments exist in every
life and can be recognized to help promote
self-esteem

• Life-review discussions, taping oral histories

and compiling a scrapbook of life events
– Feel a sense of worth about the lives they have
lived
– Sense of history and legacy to younger
generations
• Helping patients participate in relevant
activities
• Engage in meaningful social interactions
• Have opportunities to do for others
• Exercise a maximum amount of control
possible over their lives
• Maintain religious and cultural practices
• Be respected as individuals
 Nursing Considerations for
Mental Health Conditions
Managing Behavioral Problems
• Behavioral problems are actions that are
annoying, disruptive, harmful or generally
deviate from the norm and tend to recurrent
in nature
• Physical or verbal abuse, resistance to care,
repetitive actions, wandering, restlessness,
suspiciousness, and inappropriate sexual
behavior and undressing
• These problems occur in persons with altered
cognitive status who are incapable of thinking
rationally and making good judgments
• Assessing the cause of the behavior is the first
step in assisting patients with behavioral
problems
• Factors associated with the behavior should
be closely observed and documented
• Information:
– Time of onset, where it occurred, environmental
conditions, persons present, activities that
preceded, pattern of behavior, signs and
symptoms present, outcome, measures that
helped or worsened the behavior
• Factors that precipitated the problem should
be avoided, if possible

• Staff or caregivers can prevent behavioral

problems by identifying signs and symptoms
that precipitate the behaviors and intervening
them in timely manner

• Maintain a room temperature between 21 to

24 ˚C; or 70 to 75 ˚F
• Avoid busy patterns on walls, prevent
dramatic transition from daytime to nighttime
darkness, limiting traffic flow, control noise,
installing safety devices (video cameras,
alarms on doors)
 BEHAVIOR POSSIBLE CAUSE NURSING ACTIONS
Dementia Avoid putting person in situations
that trigger behaviors
Paranoia Recognize warning signs (ex.
Cursing and pacing)
Misinterpretation of Get help to protect self and
Violent/ physically actions of others others
abusive (ex. Hitting, Address in calm, quiet manner
kicking, and biting Anger Distract
others Move person to area away from
Feeling Powerless others

Anxiety

Fatigue

Dementia Avoid arguing, reasoning, and

reacting to comments
Verbally abusive (ex. Feeling Powerless Distract with activities
Insulting, accusing, and Reinforce positive behaviors
threatening) Allow maximum decision making
Anger and participation
 BEHAVIORS POSSIBLE CAUSE NURSING ACTIONS
Dementia Prepare for activities
Break activities into single, simple
Misinterpretation of actions,
steps
objects, and environment
Resting Care Use alternatives if possible (ex.
Depression sponge bath instead of tub bath)

Dementia Ensure clothing is clean, dry, replace

as necessary
Soiled clothing
Examine clothing for irritation, poor
Irritation from clothing fit
Undressing Inspect skin for irritation
Feeling too warm Redress
Inappropriately
Use clothing that is difficult to
unfasten
Offer positive reinforcement when
person remains dressed

Dementia Ignore
Distract with other activities
Agitation
Repetitive Actions Replace with more acceptable
Anxiety repetitive activities (ex. Folding
laundry)
Boredom
 BEHAVIORS POSSIBLE CAUSES NURSING ACTIONS
Dementia Schedule times for supervised walking
Provide activities
Boredom Safeguard environment
Wandering
Restlessness Ensure person is wearing some form of
identification
Anxiety Familiarize with environment
Dementia Provide daytime activities
Provide late day exercise
Excess daytime sleeping Toilet before bedtime
Night Wandering, Keep night light on in bed and
Misinterpretation of environment
Restlessness bathroom
Sundowner syndrome Reassure and orient when person
awakens
Medications (sedatives, Safeguard environment
hypnotics, diuretics, laxatives)
Dementia, leading to poor Relocate person to private area
judgment, loss of inhibition Distract with other activities
Set limits and remind of acceptable
behaviors
Inappropriate Sexual
Review medications that can cause
Behavior Misinterpretation of actions and reduced inhibitions (anti-anxiety drugs)
messages from others or increase libido (L-dopa)
Provide acceptable means of touch,
human contact
 BEHAVIOR POSSIBLE CAUSE NURSING ACTIONS
Suspiciousness Paranoid State Assess cause
Dementia Do not react to behavior;
depersonalize
Suspicious personality Protect from harm
Medications (ex. Provide explanations,;
anticholinergic, L-dopa, prepare for activities,
and tolbutamide) changes
Afford maximum decision
making
Do not try to explain to
person that suspicions are
unfounded or wrong; this
will not be helpful
Aging and Mental Health