Aging and Long Term Care (6 hours)

Overview

This course reviews aging from a biopsychosocial perspective, with a focus on long-term care. It is written by a therapist with experience as a clinical coordinator and case manager for residential care and skilled nursing facilities.

The mental health professional can play a vital role in the well being of older individuals and their families and caregivers. Therapists can help aging individuals restore and maintain meaningful activities and strong self worth. Therapists can help families and caretakers improve their support for the aging individual as well as their own well being.

This course reviews mental health challenges of aging. These include adjustments to change and loss, cognitive changes, psychiatric disorders, and recovery from abuse, exploitation and neglect. The anticipated population of older persons relative to younger wage earners will produce strains in the systems of care that will lead to increased mental health and family stress issues. This course will review the demographic changes and challenges to staff and family members posed by these changes.

The older population is highly vulnerable to abuses such as fraud, violence, and neglect. Legal and ethical issues are covered, primarily regarding reporting of suspected abuse, exploitation, or neglect.

Objectives

In the following topics, this course will enable clinicians to:

Aging Trends in Demographics

Cite the current trends of aging in the United States.

Recognize the financial, health, mental health, and housing needs of the aging population.

Long-Term Care

Define long-term care.

Identify various types and purposes of long-term care.

Understand long-term care issues pertaining to the aging population.

Help older persons recognize and cope with their changing needs in areas such as level of care.

Concerns about Long-Term Care

Identify the drawbacks or risks of skilled nursing facilities.

Help older persons and their families take a balanced and proactive approach to concerns regarding long-term care facilities.

Help older persons and their families take preventive and reactive actions regarding their concerns about long-term care facilities. This includes making licensing complaints.

Abuse, Neglect

Recognize manifestations of abuse and neglect that are of special concern in the older population, such as fiduciary abuse.

Report suspected abuse and neglect according to legal standards, including the limits of confidentiality.

Describe causes and dynamics of abuse and neglect of older persons.

Explain issues of special importance regarding abuse of older persons.

Respond more effectively to suspected abuse and neglect of older persons.

Distinguish between consensual sex and sexual abuse.

Religion, Spirituality

Describe the role of religion and spirituality in enhancing the well being of the elderly.

Distinguish between religion and spirituality.

Relate effectively to the spiritual and religious needs of older persons and their families.

Mental Health, Psychiatric, Well Being

View aging from a biopsychosocial perspective.

Distinguish between trauma symptoms or depression and normal problems of aging.

Identify mental health problems in the elderly that can easily be missed.

Respond to mental health issues to which the older population is vulnerable.

Describe issues pertaining to drug and alcohol abuse in the aging population.

Special Topics, Caretaking

Respond to family and caretaker issues related to older persons.

Communicate effectively with families that have aging-related issues, and help them improve their communication and recognition of such issues.

Help family members and caretakers learn how to help from a distance, managing matters by telephone and other means.

Assist older persons and their families in making decisions regarding dependent adult children or grandchildren for which the elder is currently taking responsibility.  

Describe the issues challenging caregivers.

Aging Optimally

Describe the difference between cognitive problems that occur near end of life, neurodegenerative disease, and normal cognitive difficulties of aging.

Recognize the difference between stereotypes of the elderly and more typically mild cognitive problems.

Describe the philosophy of optimal aging.

Educate older persons, staff, family, and caretakers regarding issues that can reduce stress and improve well being.

Resources

Access resources of value in treatment and education of clients with aging issues.

Refer clients to resources pertaining to housing, abuse, and other matters related to aging and long-term-care needs.

 

"Grief takes many forms. But don't worry, we're here to help you fill them out."
- Mike Baldwin

Demographic and Fiscal Challenges

Dramatic growth: The U.S. is challenged by dramatic growth in the aged population. This is the result of the baby boom that took place between 1946 and 1964 following World War II. As of 2011, this generation of “baby boomers” has begun reaching the age of 65. This surge will continue through 2029. This will place greater stress on families and care systems than any previous period.

Demographics: The Administration on Aging (2011) provides the following statistics on this aging trend:

A Profile of Older Americans: 2010

The Older Population

The older population--persons 65 years or older--numbered 39.6 million in 2009 (the most recent year for which data are available). They represented 12.9% of the U.S. population, over one in every eight Americans. The number of older Americans increased by 4.3 million or 12.5% since 1999, compared to an increase of 12.3% for the under-65 population. However, the number of Americans aged 45-64 – who will reach 65 over the next two decades – increased by 26% during this period.

In 2009, there were 22.7 million older women and 16.8 million older men, or a sex ratio of 135 women for every 100 men. The female to male sex ratio increases with age, ranging from 114 for the 65-69 age group to a high of 216 for persons 85 and over.

Since 1900, the percentage of Americans 65+ has more than tripled (from 4.1% in 1900 to 12.9% in 2009), and the number has increased almost thirteen times (from 3.1 million to 39.6 million). The older population itself is increasingly older. In 2008, the 65-74 age group (20.8 million) was 9.5 times larger than in 1900. In contrast, the 75-84 group (13.1 million) was 17 times larger and the 85+ group (5.6 million) was 46 times larger.

In 2007, persons reaching age 65 had an average life expectancy of an additional 18.6 years (19.9 years for females and 17.2 years for males). A child born in 2007 could expect to live 77.9 years, about 30 years longer than a child born in 1900. Much of this increase occurred because of reduced death rates for children and young adults. However, the period of 1990-2007 also has seen reduced death rates for the population aged 65-84, especially for men – by 41.6% for men aged 65-74 and by 29.5% for men aged 75-84. Life expectancy at age 65 increased by only 2.5 years between 1900 and 1960, but has increased by 4.2 years from 1960 to 2007.

About 2.6 million persons celebrated their 65th birthday in 2009. In the same year, about 1.8 million persons 65 or older died. Census estimates showed an annual net increase of 770,699 in the number of persons 65 and over.

There were 64,024 persons aged 100 or more in 2009 (0.2% of the total 65+ population). This is a 72% increase from the 1990 figure of 37,306.

The elderly population has diverse needs for care. Approximately 10% of people over age 65 live in their communities and require some level of long-term care. An additional 5% are in nursing homes. After age 65, nearly half of Americans spend some time in a nursing home. Nearly 75% will require some form of home care. (Stone, 2000)

Analysts and policymakers are raising concerns regarding the capacity of nations affected by a projected severe imbalance between young and old. Demands on society include costs, service design and delivery, and recruitment and training of the needed labor force. Although these questions have been debated since the 1970’s in the U.S., analysts are concerned that there is not enough political will to prepare adequately. One area of concern is the need to develop an adequate labor force. (Stone, 2000) **current

Need for care services: Regarding the need for long-term care, the Administration on Aging (2011) tells us that, "About 11% (3.7 million) of older Medicare enrollees received personal care from a paid or unpaid source in 1999. The older population has diverse needs for care. Approximately 10% of people over age 65 live in their communities and require some level of long-term care. An additional 5% are in nursing homes. After age 65, nearly half of Americans spend some time in a nursing home. Nearly 75% will require some form of home care. (Stone, 2000) **current

National mental health crisis: Cassels (2011) points to research showing that “a national geriatric mental health crisis is brewing…” The author states that early indicators, such as increased emergency room visits by older persons not only foreshadow the needs of the baby boomers, but also arise from the limited availability of services only being made worse by the nation’s economic distress.

The author cites as an example of lack of services for older persons suffering from psychiatric symptoms, “A study presented here at the American Psychiatric Association (APA) 2011 Annual Meeting shows a 30% increase over 1 year in geriatric psychiatric visits that included longer length of stays.” One of the symptoms of the problem is older persons being placed in levels of care that are inadequate for their psychiatric needs. This results in patients being discharged from long-term care and other facilities for behavior problems such as combativeness. Burned out caregivers sometimes bring their elderly charges to emergency rooms out of desperation. “…between 2009 and 2010, there was a 2-fold increase in such calls made to the Honolulu police due to elderly patients attacking their caregivers.” (Cassels, 2011) This is one aspect of the care challenge referred to as the silver tsunami.

Life Transitions, Relationships, and Meaning

Personal Challenges

Big adjustments: The biological impact of aging can involve many challenges to physical health and functioning. These challenges translate into stress upon family and caretakers as well as the aging individuals. These stresses can pose serious mental health challenges posed by adjusting to loss and change. Such stress can trigger latent or remitted mental illness.

Stress and mental health issues: It is very important for the mental health professional to fully appreciate the impact of aging-related stress. Of course, this is difficult to do without experiencing such stresses. Specifically, the frustration, grief, and insecurity that seniors and family members experience in reaction to stress and loss can be profound. For the elderly, the diminishment of cognitive functions can multiply such reactions.

Slowed and impaired aural (hearing) processing of speech can cause stress and reduced social activity. With increasing age, individuals are likely to have difficulty processing speech and distinguishing speech and other important sounds from background noise. The earliest manifestation may be that the individual loses interest in socializing in crowded environments such as busy networking meetings or enjoyable social events because of the resulting difficulty in conversing. This language-processing problem may be further compounded by the development of hearing problems. These social activities become awkward and frustrating, forcing the individual to take a more passive role.

Note that this limitation begins as the result of a single impairment. It requires little imagination to recognize the challenge of adjusting to limitations imposed by growing and multiplying disabilities. To put this into perspective, imagine the extreme frustration of having great difficulty taking care of typical daily tasks while having trouble seeing, becoming fatigued by pain, and even finding eating to be challenging because of trouble with chewing and digestion. Compound that with difficulty thinking clearly, and you have trouble getting cooperation from others, difficulty controlling one's affairs, losing things, and being taken advantage of by predatory con artists.

A great source of stress is insecurity about the future; not just in terms of health or functioning, but in terms of money and housing. The more stresses mount, the more of a toll they can take. Mental health providers serve a very important role in helping people come to terms with their stress triggers and adopt a more planful, objective, and positive approach to their changing circumstances. Treatment research that will be discussed later gives much support for the role of psychotherapy in the lives of older persons and their loved ones.

Relationship and Family Matters

Trends: People are likely to live well beyond 65. The result is many older persons who are separated or widowed. We are likely to see increasing numbers of non-institutionalized individuals living alone. (AOA, 2005) **current

Relationship and family issues: Even good relationships can become quite stressed by challenges of aging. These can include difficulties with adjustment to loss, cognitive changes, health issues, retirement, and financial difficulties. Changes in roles often trigger relationship difficulties. 

Some transitions are especially difficult to tolerate. This can include adjusting to financial problems or outright crises.

Recognition and communication: Sometimes one or more family members discover that an older family member needs assistance. This may be the result of an accident or medical event such as a stroke. It may be from a family member realizing that their older family member is beginning to show signs of trouble, such as poor hygiene or disorganization. Families that communicate well may learn earlier on through self-disclosure by the older family member. Family members may need assistance in overcoming communication barriers such as ongoing conflict or personality differences in order to coordinate their efforts for the sake of their older family member.

Family members are often in the best position to recognize problems, but some of them are subtle and they are often missed. Depression and alcohol or prescription drug abuse are frequently overlooked or rationalized away. Signs of abuse are important to recognize, but may be nearly invisible, especially in the case of some kind of fiduciary abuse. The only way a family member may realize there is a problem with driving is by taking a ride with the older person. Problems such as macular degeneration can make driving a matter of life and death.

Older family members are likely to resist proposed changes. Family therapy can help family members plan and cooperate. When there is legitimate fear of the older family member coming to harm, the therapist's familiarity with social services can help family members respond. Family members often approach the older person in an overly forceful or assertive manner that causes the older person to feel that they are trying to take over their lives. This can be prevented by means such as being prepared with carefully chosen words, and priming the older person to be more receptive. Therapy can help family members avoid becoming emotionally overwhelmed or to recovery from emotional stress arising from the situation. Just having a workable and realistic plan can diminish caregivers' and family members' stress a great deal. The analytical skills of a social worker or therapist can be of great assistance in developing such a plan.

Long-distance caregiving: Family members that want to help may live too far to be present often enough to have the impact that they desire. However, they can do a great deal from a distance through means such as communicating with other caregivers such as professionals and facilities by telephone and email. According to D'Aprix and Alexander, (2011), "Nearly 50% of long-distance caregivers devote one full work day a week to managing their loved one's needed services."

This will require getting releases of information to the person's health professionals where personal health information is to be discussed. The long-distance caregiver should maintain notes and copies of all forms in case they are needed. They can act as a librarian by keeping essential information such as financial documents and records organized. Long-distance caregivers, with permission and security information such as passwords, can manage finances online.

Older persons caring for grandchildren or dependent children: **major edits put in 3 unit Older persons may be in caretaking roles that they are becoming unable to fulfill adequately. Their adult children may not be able to care for their own children because of factors such as mental illness, drug addiction, or imprisonment. About 475,000 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them. (Administration on Aging, 2011) Many such grandparents are not willing to see their grandchildren relegated to foster care or subjected to neglect or abuse by their child.

Poorly functioning adults may not be prepared for independent living. The parents or grandparents must be helped to use resources for this transition. Developmentally disabled individuals such as those with Down's syndrome should have independent living skills training and case management as needed. Some mentally ill adult children may be benefiting from their parents' or grandparents’ support, but pose so much risk, that other arrangements will be necessary.

Clinicians can play an important role in helping older persons accept these transition points and develop a more realistic perspective regarding the needs and risks involved. The clinician can help to link clients with appropriate social services and information sources. 

Dynamics of abuse, danger, and neglect: Older persons are at increased risk of abuse, neglect, or of being a danger to themselves or others. This is certainly true in informal caretaking situations such as home care, but there are also risks in care facilities.

Concerns about facilities and bad outcomes: What is the answer for families that don't trust facilities? At least part of the answer is in being educated as to resources and strategies to improve safety and care, and to correct deficiencies when they occur. Here are some of them:

Informal monitoring: Family members visit regularly or even augment care by providing a lot of time on site. These same individuals make observations, take notes, take pictures or video, and ask questions regarding care.

Advocacy on site: Family members encourage staff to take appropriate actions to prevent or resolve problems.

Advocacy off site: Family members contact the Ombudsman's office or licensing agency to direct their attention to identified problems. Notes and media can help verify these concerns. Agency staff may be motivated by concern that, should there be a bad outcome, damning media would be made public.

Legal action: Sometimes, it is so frustrating and difficult to get proper care that family members take legal action or engage in mediation through the Ombudsman's office

Filing complaints: Verifiable problems such as a bed sore or even matters such as non-compliant staffing patterns can be legitimate reasons for filing a complaint with the appropriate authority.

Filing a complaint serves three primary purposes:

1) Helps get information about what a facility may have done improperly with respect to taking preventative steps or care. This information can get the licensing agency to take action that improves care. It can also be useful if a lawsuit is brought against the facility.

2) Creates a record that becomes part of the facilities ‘track record’. Many times these reports can help families select a facility for their loved ones.

3) Create an incentive for facilities to improve care. Facilities do not want negative publicity.

The Federal Older Americans Act requires all states to have a long-term care ombudsmen program. Ombudsmen act as patient advocates for persons in long-term care facilities. This includes helping with investigations of complaints or incidents. They also help families find facilities, address problems in long-term settings, and help people understand their legal rights pertaining to long-term care. Additionally, complaints may be lodged with the state department of health. Most have some type of division specializing in these matters.

The Resource section includes links to agencies and organizations with diverse resources and information. Families looking for housing options should contact their local Area Agency on Aging, Center for Independent Living or Aging and Disability Resource Center. Local city government may also be able to provide guidance.

Many of the rights that seniors need help with are covered by The Fair Housing Act. It applies to a number of different settings that people call home. It prevents discrimination based on disability. In addition to places such as apartments, it also applies to nursing homes, assisted living facilities, and senior communities. For example, a landlord (or residential setting) may not prevent a resident from making modifications in the home necessary to accommodate a disability. The U.S. Department of Housing and Urban Development (HUD) has more information on this.

Families and older persons needing to make decisions regarding long-term care and funding can get an overview by reading Piecing Together Quality Long Term Care from The Consumer Voice at http://www.theconsumervoice.org/piecing-together-quality-long-term-care

Challenges to adapting: At first, creative adaptations are fairly accessible and easy to arrange. However, additional losses of functioning can further challenge adaptation. Individuals who are not very resourceful will have the greatest difficulty accommodating the demands of aging. While everyone may benefit from mental health services and consultation in coping with the issues of aging, less resourceful individuals may quickly develop a desperate need for mental health intervention and other accommodation and treatment. These individuals may be having difficulty adjusting because of early progression of Alzheimer's, or longer-term emotional or intellectual impairments that have resulted from problems such as trauma, mental illness, substance abuse, or brain injury. Multi-problem families stand to become all the more dysfunctional as they rely on inappropriate coping behaviors in reaction to issues of aging.

Stereotypes and Neurodegeneration vs. normal cognitive slowing: It is important to distinguish between commonplace age-related changes in cognition and lower intelligence. The stereotype of the confused or doddering elderly person is based on individuals who are suffering from a more significant difficulty such as emerging Alzheimer's (a neurodegenerative disease).

It is true, though, that as we age it is normal for us to experience some slowing in our cognitive functions. There is a mild loss of cognitive efficiency, and this can make it somewhat more difficult to be as organized as we would like. An essential factor is that short-term is exactly that: it is short-term in the sense that it fades rapidly. Thus, a loss of cognitive speed can make it more difficult to fully use short-term memory. The result can be some forgetfulness or disorganization. As we age, we can learn to accommodate for this somewhat. However, it can still lead to the occasional embarrassing "senior moment."

The point here is that this loss of efficiency does not represent a significant decline in overall intelligence or judgment. It is more of an inconvenience than a disability. Most people who were well-informed and perceptive as younger people continue to enjoy these traits and to make meaningful contributions well into their later years. It is usually not until serious health problems emerge toward the end of life that substantial losses of intelligence actually occur.

If anything, negative stereotypes and attitudes of others can create a self-fulfilling prophecy because of the effect of environment and expectations on our performance. (Mather & Carstensen, 2005) Staff and caretakers should be trained to bring out the best in older persons. A growing body of research and practice tells us that humanized interaction and environments can produce significant changes in the well being of residents, and even improved behavior in individuals who have emotional or mental symptoms.

Optimal Aging: Despite the challenges and stereotypes, the majority of aging individuals have a substantial commitment to well being and take advantage of benefits of experience. For example, overall, older persons tend to have better management of moods and have a more positive outlook. (Mather, & Carstensen, 2005) The concept of optimal aging has also been referred to as successful or healthy aging. 

The three primary areas indicative of optimal aging, according to Mather and Carstensen (2005) are:

1. Low probability of disease or disability;

2. High cognitive and physical function capacity;

3. Active engagement with life.

It is important to remember that these optimal aging factors are goals that guide people in their lifestyle choices. If a person is ill, this does not mean they have failed to age optimally. It means that they have the challenge of improving their health as much as possible, and deriving satisfaction from the areas of their life that are the most rewarding. Optimal aging can be viewed in the same domains as those comprising a mental health and wellness assessment for the general population.

Income challenges: **put me into 3unit

The elderly are especially vulnerable to financial problems that amplify their risk of poorly treated health issues. The Administration on Aging (2011) provides statistics showing that many elderly persons are faced with significant financial problems:

Almost 3.4 million elderly persons (8.9%) were below the poverty level in 2009. This poverty rate is statistically different from the poverty rate in 2008 (9.7%).

The median income of older persons in 2009 was $25,877 for males and $15,282 for females.

Households containing families headed by persons 65+ reported a median income in 2009 of $43,702.

The major sources of income as reported by older persons in 2008 were Social Security (reported by 87% of older persons), income from assets (reported by 54%), private pensions (reported by 28%), government employee pensions (reported by 14%), and earnings (reported by 25%).

Social Security constituted 90% or more of the income received by 34% of beneficiaries in 2008 (21% of married couples and 43% of non-married beneficiaries).

One aspect of the older population's vulnerability is apparent in these numbers from the report:

About 30% (11.3 million) of non-institutionalized older persons live alone (8.3 million women, 3.0 million men).

Half of older women (49%) age 75+ live alone.

Employment issues: Older persons generally wish to retire. A minority of older persons continue to work. Most have hoped to use retirement to do other satisfying activities. Clients may need assistance in coming to terms with forced choices that result from economic necessity, health issues, or age discrimination. The expectations with which individuals enter their later years often have a great impact on the manner in which they respond to demands of life. Increased longevity and income pressures are extending the working lives of Americans, but this new emerging norm should not obscure care and retirement needs of the aging population.

Physical activity: A shocking number of older persons do not maintain adequate levels of physical activity. (CDC, 2002) From age 45, physical levels of persons involved in regular physical activity go from 30% to lower levels. By ages 75 to 84, 20% are reported to have adequate levels. Because of the benefits to well being and mental clarity that physical exercise create, professionals should assist older clients to adopt appropriate levels of activity that are gratifying. Some physical activities have the added benefit of social involvement, such as walking groups and gym memberships. Social networking sites such as MeetUp.com can be helpful in finding or starting activity groups locally.

Identity, End-of-Life, and Dementia

Dementia as emblematic of end-of-life issues: There are many end-of-life issues that elders, family members, and professionals must grapple with, such as euthanasia, when to terminate life-sustaining treatment, and assisted suicide. These issues are intimately tied to matters of free will and identity. Dementia is a medical condition that brings these issues and more into the foreground. Growing old and experiencing decline pose challenges to our identity and closest human relationships. As old as these issues are, we are experiencing them in a new context, that of modern medicine and its effects in increasing the healthy and active lifespan, as well as the years of dependency and decline.

According to panelists on The President's Council on Bioethics (2004a) quoting American Psychiatric Association publications, roughly 15% of older Americans suffer from dementia in some form. Of this group, 60% suffer from Alzheimer's disease. About 1 million**current of them have severe symptoms, with another 3 million being mild to moderately impaired.

Cognitive and memory loss affecting relationships: Memory loss and cognitive impairment can cause significant changes in the personality of the individual, and memory loss can blur or even eclipse life-long relationships in the sufferer's mind. Nonetheless, in some combination of obligation, attachment, and love, families generally maintain the bond and commitment to the affected individual and go to great lengths to support them in being as independent and comfortable as possible. 

A source of conflicts: Where there is severe cognitive impairment, such dynamics can create a collision between three factors in particular: The desires of the older individual as perceived by the family, the recommendations of medical clinicians, and any directives left by the older person. This can include conflict between family members as well as the presumed or actual conflict between an advance directive and the elderly person's current life satisfaction.

A highly dependent and low-functioning individual whose "past self" would have elected die before becoming so dependent and impaired may now be taking satisfaction in simple tasks. It can be argued that the person as they are now cannot be affected by a directive made by a "past self" that should no longer be considered as a viable decision-maker when it comes to end-of-life decisions. (The President's Council on Bioethics, 2004b) The conflict that occurs within the family often centers around the interpretation of a dying and dependent person's preferences when decisions around treatment and withdrawal of life support must take place. Parents and siblings are more likely to desire heroic measures, while spouses are more likely to favor termination of life support sooner. Most likely, there is a mix of selfish and altruistic motivations at play in these positions. These conflicts are compounded by the fact that many advance directives are too vague or do not adequately address the issue at hand. As society gains experience in these matters, advance directives are becoming more effective and sophisticated. **cite

Loss as a fundamental: At the root of many such conflicts is grievous loss. The person is still physically present, but family members and friends experience a loss of the person they knew. They may not be able to express it because of shame. The therapist can help them recognize and deal with this grief. They benefit from being validated and helped to discover how they are moving into a new, positive chapter in their lives. 

Palliative care: It is a myth that the elderly experience pain less than other age groups. It is also inappropriate to think of pain as a character-building experience, certainly not in the older population. For these reasons, palliative care is intended to enhance comfort rather than engage in life-saving medical procedures. However, palliative care does not necessarily obstruct the provision of other medical treatment.

Advance Directives: This is not just an issue for attorneys and family members. End-of-life and late-life care decisions are source of conflict that can benefit from family therapy. Older persons and their families can be encouraged to engage in this planning in a structured manner that can assist them in processing the matter effectively.

Mueller (2001) describes a structured process of advance care planning that can be mediated by professionals and that has shown positive outcomes in research:

In advance care planning, patients articulate their values, goals, and preferences about their future health care should they lose capacity to make decisions. This process involves identifying a surrogate decision-maker and documenting the process in the patient's medical record and in an advance directive. 

The author states that, “Elders' wishes were more likely to be known and respected when nurses or other health workers guided them through the planning process.” Their research involved the Respecting Choices program.

Religion and Spirituality

Diversity and quality care: Spiritual or religious questions may arise in patients, even those who have a history of firmly rooted beliefs. These reactions range from mild crises in faith, to manifestations of psychiatric illness that may be overlooked. Questions such as, "How could God let this happen this way?" and "Why would God's will create such suffering in the world?" may sound the same in a normally grieving person and a person experiencing a mood disorder.

The guidelines of the Joint Commission on Accreditation of Healthcare Organizations require hospitals to meet the spiritual needs of patients. (Lavretsky, 2011) Therapists should be prepared to embrace the diversity of religious and spiritual beliefs of clients and family members, as well as staff members. Improved understanding and respect for an individual's spiritual practice can help shape personalized medical care for older adults, and improve health outcomes.

Well being: Research on the physical and mental health outcomes of spiritual or religious involvement and belief suggest that they are conducive to improved mental health and possibly physical health as well. However, it is difficult to interpret the research because a) differing definitions of religiosity and spirituality make it difficult to compare research studies, b) traits conducive to such beliefs and involvement may be causal factors independent of religious activities, and c) involvement in social and mental activities may be responsible for the improvements noted. There appears to be a higher level of health-promoting activities and prohibitions among those higher in religiosity, and this may account for greater health and longevity detected in this population. (Lavretsky, 2011) “A study of over 20,000 US adults estimates that religious involvement prolongs life by approximately 7 years.” (Lavretsky, 2011) At the minimum, people with health problems and who are nearing the end of their lives are likely to rely on religion to mollify their emotional suffering.

Definitions and feelings: The National Interfaith Coalition on Aging defines spiritual wellbeing as the affirmation of life in a relationship with God, the self, the community and the environment that nurtures and celebrates wholeness. (Lavretsky, 2011) Non-religious people that pursue spirituality tend to adhere to a personal or group definition of spirituality that emphasizes achieving peace of mind and accepting meaningful challenges that align us with our highest values.

They may incorporate secular spiritual practices such as meditation. Organized secular activities along these lines take place through venues such as the Unitarian Universalist Church. The Buddha’s exhortation to meditate as a means of ending suffering appears to be getting support through neurobiological research showing that meditation improves introspection and emotional self-management. The Mindfulness-based Stress Reduction Program (MBSR) is a secular approach to stress management that has gained some popularity. Yoga, when provided according to the physical needs and capacities of the participants, can not only enhance physical functioning, but also promote stress management through its mindfulness-promoting properties.

Two common elements of spirituality appear to be at odds, but can be integrated philosophically. They are achieving peace of mind and accepting challenges that can take us outside of our comfort zones. These words appear to capture, in part, the sentiments of many spiritual people. Religiosity is distinct from spirituality in that it emphasizes specific religious beliefs and practices, and often includes alignment with the doctrine and activities advanced by their religious institution. In major deistic religions, acting on the will of a god is generally paramount. Therapists must recognize that people may be high in religiosity, spirituality, or both religiosity and spirituality. (Lavretsky, 2011)

Relating to client and caretaker beliefs: Specialized training in responding to spiritual concerns can help the therapist navigate this territory, regardless of their personal beliefs. We can learn to be neutral, yet support the client's quest for meaning. For example, the therapist may say, "You have found meaning in scripture before, haven't you? Can you tell me more about that?" Or, "People want to know these answers right away, when they are in the middle of their pain, but you may do better by accepting the gift of time that you have now, as you heal from this, as countless people before you have healed." Or, "You can give God time to answer you, by taking the time to write a letter to God. You can get your thoughts and feelings out, and this can help you feel better."

Medical or other life event stress, and cognitive effects of aging may produce hyper-religious attitudes that may have an adverse effect on socialization or involvement in medical care. (Lavretsky, 2011) Therapists must be sensitive to the role religious attitudes play in the client’s well being, and contribute to health-promoting attitudes and behavior where possible.

A 1997 Gallup poll found that nearly 70% of people in the U.S. said that they would want their physician to address their spiritual issues if they were in distress. Most likely, this number would be higher for psychotherapy. Given the diversity of spiritual practices and beliefs, this requires that the therapist at least be prepared for various scenarios, and accept the profound feelings that others have about beliefs that may be quite different from those of the therapist.

One answer is so obvious, it's almost invisible. The therapist can ask simply, "How would you like me to address this (spiritual issues brought up) in our work?" There's no reason for the therapist to try to read the client's mind. Also, the therapist can use the client's beliefs as a gateway to interventions such as getting the client involved in their faith community in some way in order to create more support. Most likely, there is a range of options. Even homebound individuals have options such as visits, phone calls, online support, and recorded media.

A quick assessment of spiritual issues take the form of the FICA Spiritual Assessment, and it has nothing to do with the client's credit score:

Faith or beliefs: Tell me something about your faith or beliefs.

Importance & influence: How does this influence your health or well being?

Community: Are you part of a supportive community?

Address or application: How would you like me to address these issues?

Roles and goals: Training of therapists and medical professionals for integration of spirituality in practice goes as far as to suggest that, when religious authorities such as chaplains are not present, the therapist or other care professional can provide some aspects of religious rituals or services for their clients. This involves certain practical and ethical considerations that make it a viable practice that clients can appreciate.

Non-religious clinicians may feel duplicitous in supporting clients' religious beliefs, though they recognize that many people function better with such beliefs supported. On the other hand, religious therapists sometimes feel a drive originating in their own religious beliefs to save clients that are not on a religious path. We must remember that clinicians are ethically restricted from imposing their beliefs on others, and are cautioned not to undermine others' beliefs. People come to therapists during times of heightened stress when they are vulnerable. Imposing an agenda based on the therapist's desires is an ethical breach. Our ethics dictate respect for diverse beliefs.

Research shows that religious affiliation can be a good source of social support and engagement. However, research has repeatedly failed to support the theories that prayer, intercessory (distance) prayer, visualization, or energy work heals. However, these interventions can function as part of a stress management program.

Patients or their family members may have spiritual or superstitious beliefs that may interfere with medical decision-making. (Lavretsky, 2011) This may involve keeping the patient on life support until God decides it's time for them to die. It may involve refusing treatment because what is happening is God's will, or because they believe in and expect miracles. This may result in legal intervention. 

Aging and Psychiatric Symptoms

Introduction

Social service and mental health professionals may need to cope with challenges posed by older clients and their families and caretakers. Clients with cognitive impairments may ruminate about things that the clinician cannot do anything about. Some of these clients will not be very responsive to attempts at expanding the discussion to more valuable areas. Loss of impulse control or emotional stability may result in disturbing or insulting statements or lashing out by the client. Suspiciousness and accusations are very common. Clients may begin misplacing things and fear that others are stealing from them.

The client's position of dependence on staff, family, and other resources can be disturbing to the client. Most people are very uncomfortable being relegated to a role that feels childlike. Of course, guidance by professionals to family and staff to respectfully emphasize choices and independence as much as possible will help the client from feeling that others are infantilizing them or being condescending or oppressive.

Some clients will have a limited ability to benefit from direct counseling. For these situations, the clinician's role will be more focused on working with family members or staff. This calls for care in defining roles and boundaries as well as in navigating issues of confidentiality. The clinician may be functioning more as consultant and case manager than psychotherapist. Social work and case management ensures that all resources, including family members, are contributing as much as possible to client's well being. In family therapy, the therapist has individual clients, and the family as a whole. In some cases, the older family member will have no interest in what the clinician has to offer. The clinician may have been brought in by other family members. Here, the therapist will be working for the welfare of the older family member, but through the family members. This requires clarity on any ethical issues that arise. However, there is no ethical proscription against helping family members "finesse" the person they are concerned about. In fact, by helping family members understand the resistance or avoidance by their older member, they may be able to act more compassionately, ethically, and effectively in pursuing their aims.

Therapists may need to define their role as doing family therapy, thus having multiple clients. Some therapists who are not used to functioning outside of a counseling role will need to expand their thinking and roles into psychosocial issues and very active case management. In some cases, the therapeutic relationship will be with one or more family members who are attempting to do their best with an elder member who has no interest in talking with the therapist, or a very limited ability to benefit.

Issues of death may be taxing to clinicians that must come to terms with losing their clients and seeing families and caretakers through intense grief. Grievous losses can be traumatic and lead to symptoms in all parties, including clinicians. Training in grief work is very important to ensure that the clinician feels confident and resourceful, as well as able to detect their own needs for assistance with these issues.

Much of grief work is a matter of facilitating expression and staying supportive, yet out of the way so that the process of grief can take place. An appreciation of the grief process as a part of life and a gateway to a new chapter of life is helpful.

Depression

Risk

There is a higher risk of depression in the elderly. The limitations and losses of aging can create situational depression. Clients with dissatisfaction regarding their lives, particularly those with characteristics of personality disorders, may experience intense or smoldering feelings about the lives and experiences that they feel they should have had, but didn't. The deaths of loved ones may leave clients with much unresolved grief and a lack of support that was there in the past. Those who were unable to create supportive, intimate relationships may have great regret. Any missed opportunities may loom large in their minds. This may include abortion, lack of children, business or career failures, loss of money to illness, any failures in life, rejections, having been misjudged, or having been betrayed in any way.

Disregulation of the brain can cause dark moods and inability to become free of rumination over negative experiences and circumstances. The diminished activity caused by depression is a risk factor for obesity and other health problems.

10% to 22% of the non-institutionalized elderly display depressive symptoms, with women being nearly twice as likely as men to have them. The following table from the Health and Retirement Study (AOA, 2005) provides figures for ages 65 to 85 and over.

Percentage of persons with depression symptoms, by age group:

Gender	65 and over	65-69	70-74	75-79	80-84	85 and over
Women	18	16	18	18	18	22
Men	11	10	10	10	15	15

Of individuals age 65 and over, 1% to 2% have major depression, not just depression symptoms as above.

Suicide

Older persons are twice as likely to commit suicide as the general population, with white males in this age range having eight times the risk of the general population. It is very important for the clinican to follow up on suicide risk factors, including attempt history and self-statements. Following suicide attempts, nightmares are a risk factor for further attempts. The increased access to medication in the elderly is a risk factor. Isolation, despair, and the more specific life-challenges are risk factors. Loss of spouse is among them.

Depression can compound difficulties with self-care by reducing motivation. The lack of physical movement that can lead to obesity can be made much worse by depression, increasing weight gain. Medications for depression or other symptoms may also contribute to weight gain. In turn, obesity may make activity more difficult, creating a vicious circle.

Depression Assessment

Remember that depression can have behavioral and cognitive signs. Depression signs include cognitions of worthlessness, excessive guilt, self-loathing, hopelessness, or helplessness. There can be a pervasive despondency and despair. Behavior can include diminished activity, social withdrawal, tearfulness, and suicidality, including ideation or acting out.

Encourage family members, staff, and physicians to take depression seriously, rather than writing it off as a normal experience of aging or as something that cannot be helped. Educate them regarding the value of counseling, psychosocial interventions, activity, appropriate exercise, environmental factors such as the setting and light, and medication.

Depression can be more difficult to assess in the elderly because of it's complicated overlapping with pain, normal grief, and the process of dying and having health complications.

Standard screening tools for depression such as the Beck Depression Inventory or even the Geriatric Depression scale are not validated for dying populations. There is concern that they may generate false positives. The following questions are excellent examples for getting an initial sense of potential depression. Each question pertains to a different aspect of the depression experience: time, comparability, and introspection. The final question gets the client to slow down and think, rather than offer a superficial response:

The Quick Depression Screen

Do you find yourself depressed most of the time?

As compared to other people in your situation, do you feel that you are depressed?

Inside yourself, how do you feel about yourself?

Also, consider the risk factors for depression at the end of life:

Poorly controlled pain

Advanced illness

Alcoholism or other substance abuse

Pancreatic cancer, stroke, untreated hypothyroidism

Medications

Personal or family history of affective disorder

Other pre-existing psychiatric diagnosis

Multiple losses

If it has not already taken place, a full medical evaluation for causes of depression is called for.

Treatment

Psychosocial education of clients and their family members is an important aspect of depression treatment. (Alexopoulos, Katz, Reynolds, Ross, 2001) It fosters understanding of the roles of various professionals such as psychiatrists, understanding of the mechanisms of funding for care, costs and efforts to be anticipated, medication issues, and other matters related to treatment.

Cognitive behavioral treatment of depression has been shown effective in the elderly population. **cite

Enhancing activity, intellectual stimulation, being valued, and being involved in social activities has proven helpful. Religious activities are a ready means of generating social involvement because of the ease of integration into such activities, and the structured means of involvement. Additionally, the religious beliefs of the individual can be leveraged for enhancing mood through such involvement. (Fentleman, Smith, & Peterson, 1990)

Anxiety

As discussed, anxiety is a common aging experience, and can be compounded at end of life. Dying can bring up emotions ranging from anxiety to outright fear and dread. Anxiety generally manifests in a manner similar to the non-dying population. However, persons with emerging cognitive problems may experience increased difficulty because of excessive rumination on disturbing topics such as old regrets or resentments.

Factors associated with dying that can arouse anxiety include:

History of anxiety, mood disorders, or psychological trauma

Current, legitimate fears, including ongoing abuse; Unspoken fears about being moved to another setting, losing more independence, or painful medical procedures

Fears for others' well being, not being there for them; Can include concerns about their finances or the effect of one's medical care costs on the family

Delusional or unrealistic and obsessional fears

Fearing losing control, health, independence

Fear of death as a potentially agonizing experience, or as the termination of existence. Can include existential fears pertaining to meaninglessness or hopelessness

Difficulty letting go of desires, plans, or personal connections

Fear aroused by loneliness or isolation, not having caring people

Fear of own impulses to self-harm in connection with depression. Anxiety and depression can coexist. Anxiety is often a precursor to depression

Concern about finances

It is important to understand the circumstances or psychological factors that give rise to the anxiety in order to produce a relevant treatment plan.

Assessment

To assess for anxiety, start with the client's own assessment of sources of anxiety. Rule out the above factors in discussing the client's concerns. Sorting out normal reactions to anxiety-provoking situations from other factors is important.

Treatment

Treatment for normal fears may be as simple as making sure that the client has sufficient information or reassurances about situations that are of concern. The therapist should avoid being overly reassuring when it is premature or will lack credibility. Developing a plan to address the situation may be key. When there are psychological or psychiatric issues, the treatment plan should reflect a thorough assessment. Stabilization of sleep may be a crucial element of treatment, as sleep problems may destabilize mood and cognition. If there are concerns about therapy causing excessive arousal in a medically fragile individual, the treating therapist should have good skills in preventing or minimizing abreaction to material that is highly arousing. The incorporation of visualization and hypnotic modalities may be appropriate. 

Drug and Alcohol Abuse

Factors such as isolation and anxiety can increase the risk of drug or alcohol abuse in older persons. These problems may be difficult to detect, as they may, like the other problems discussed, be mistaken for problems of aging. Caregivers and others may rationalize it as a form of legitimate self-medication that is understandable, but these problems are debilitating and potentially lethal.

Prescription drug abuse is commonplace in the elderly, especially when they have a means to acquire additional prescription drugs. They may gain access to multiple physicians that are not aware of each other's treatment. Medical professionals should be aware of drug and alcohol abuse because it has an impact on medical decisions.

Therapists can employ the same measures they would with a younger population in identifying and addressing alcohol and drug problems, but with the additional hurdles we have identified.

Near-Death Delirium

Approximately half of individuals experience delirium when approaching end of life. This can be very emotionally disturbing to staff, family, and other patients. Because it is part of the dying process, it may be very different from non-terminal delirium. It is important that people in the patient's environment be prepared and understand that it is a medical phenomenon, and that steps be taken medically and emotionally to minimize the patient's distress.

An argument for medication in these cases is the need to lower the risk of injury to patients that become agitated.

Delirium vs. Dementia: Delirium can be differentiated from dementia in that delirium is a disturbance in the level of consciousness with fluctuating symptoms and acute onset. Dementia, on the other hand, normally involves being alert with little or no clouding of consciousness. It usually has a gradual onset. The two conditions share the features of impaired memory, thinking, orientation, and judgment.

Terminal delirium is distinct from non-terminal delirium in that it is relatively refractory to clearing through medical intervention. This is because it is part of the dying process, exhibiting a more profoundly changing brain state. Non-terminal delirium usually has an underlying cause that is correctable. It can occur in any fragile patient, but is more likely to occur when the patient is very ill. Common but reversible causes of delirium at end of life include pain, constipation, and urinary retention. **cite

Be reassuring to the patient and family. Simple statements as to where the patient is and who they are with may be reassuring to many patients. It is important to maintain a peaceful environment.

When it is not distressing: Delirium may not be distressing, but merely confusing. Some patients experience pleasant visions or hallucinations. These may involve transpersonal themes such as deceased relatives, guardian angels, young children, or babies. In this case, no intervention is required. It is important to avoid medication that would increase confusion in this case, such as benzodiazepines. When it is not distressing: Delirium may not be distressing, but merely confusing. Some patients experience pleasant visions or hallucinations. These may involve transpersonal themes such as deceased relatives, guardian angels, young children, or babies. In this case, no intervention is required. It is important to avoid medication that would increase confusion in this case, such as benzodiazepines.

Trauma

The longer one lives, the more traumas one may have experienced. Treating trauma history may reduce or eliminate many symptoms. Experiences of aging have their own trauma risk, one being medical trauma. Trauma-related symptoms are more extreme in cases of complex PTSD, which is distinct from non-complex PTSD, especially in terms of emotional destabilization and changes in thought processes. Cognitive impairment may be more severe as well. Sleep problems, anxiety, rumination, re-experiencing, and cognitive impairment may be mistaken from problems of aging when they originate in trauma. A sufferer may be written off as a cranky old stereotype, when they have real clinical needs. This is an important matter of differential diagnosis. It is important to distinguish between grief and traumatic grief, because of the more serious symptoms and treatment needs of traumatic grief, which can result in PTSD.

Grief

The elderly or dying person has a different perspective of grief because they are approaching the end of life and may be experiencing degenerative illnesses that are not common in other age groups. Grief can be sharply painful, with mental suffering regarding loss or regrets. All losses potentially can cause grief, and there are many kinds of attachments. Grief can manifest in many ways. People may experience anticipatory or preparatory grief, as they see losses looming, whether it is their own functioning, their life, or that of a loved one.

People may feel shame about expressing grief, but it is difficult to control. Although there are academic stages of grief, the process is not necessarily even, and can be like a roller coaster, move in what appears to be a forward and backward progression, and can come in waves, even after periods in which it appears to be resolved. Grieving individuals vary a great deal in their openness to discussion and support. Many benefit from grief groups and therapy.

Caretakers and family members may need psychoeducation regarding grief. Well-meaning loved ones may inadvertently cause unnecessary and unproductive distress and conflict.

Complications of grief can involve serious psychiatric symptoms. The symptoms may be benevolent, as with perceived transpersonal phenomena such as seeing or hearing the deceased. However, complications may also include clinical depression or even disabling psychosis. Some cases will not show signs of resolving, and this can indicate risk of long-term disability unless resolved.

High-level risk factors include unexpected, traumatic, or violent deaths, deaths of children, multiple or repeated losses, and a history of mental illness or grief reactions.

Long-Term Care

Overview

Long-term care services include medical, social, housekeeping, and rehabilitation services needed an extended period to improve or maintain functioning and health. This section reviews some of the alternatives and issues.

A spectrum of options: Disabilities associated with aging necessitate accommodation. These arrangements span a spectrum of care. They range from support at home to medically sophisticated residential care. Arrangements can be informal, as when a family member provides regular assistance, or involve professional care. Funding may be private, involve long-term care insurance, or programs such as Medicare. Social workers and other professionals with experience in this area can assist families in pursuing arrangements and funding.

Blurring boundaries: Long-term care takes many forms and can include acute care that is part of a long-term care setting. Generally, long-term care facilities are distinct from acute care because they are normally dedicated to the overall well being of their residents and management of chronic conditions. There is no universal definition of long-term care. It may be referred to as home and community-based care when it is non-institutional. Such arrangements range from home-based care to various group living arrangements that include specialized homes called residential care facilities (RCFs). These include assisted living facilities, board and care facilities, and adult foster homes. These facilities can blur the boundaries between non-institutional and institutional care when they provide relatively high levels of care or when they are larger. Assisted living and residential care facilities range from smaller, home-like settings to larger arrangements that resemble hotels. 

Community-based care: This is a long-term care trend that is humane and cuts costs. The goal is to maintain older persons requiring long-term care in smaller, more home-like facilities in local communities when possible.

Adult day care: By providing supervision and services during the weekday, adult day care programs can fulfill the role of offering respite to family members who are caring for an elderly relative, and who need to work. This kind of program can also be a way of consolidating care among facilities during the day in order to reduce costs. Adult day care services may be provided at a larger care facility, or at a community setting. Such services may help a broad population, but some are intended for more individuals with a higher relative level of need. A large percentage of individuals benefiting from such services have cognitive impairments from dimenting illnesses such as Alzheimer's disease. Many of them need supervision and assistance, but do not require a high level of specialized medical care on an ongoing basis.

Day health model: An emerging model related to adult day care is the day health model, in which adult day care is provided to elders with major disabilities and who often have multiple co-morbidities such as heart disease, diabetes, or stroke. An example program is the Program of All-Inclusive Care for the Elderly (PACE).

Responsibilities: Long-term care provides a wide range of assistance with typical activities that individuals with chronic disabilities require over an extended period of time. You could call these services low-tech in the sense that they are intended to accommodate or rehabilitate physical or mental functioning deficits. Such facilities or in-home arrangements provide ongoing assistance with basic activities of daily living (ADLs). Depending on the level of need, these may include eating, dressing, bathing, doing laundry, cleaning, and preparing meals. This may include managing finances and medication. This care may range from being predominantly supervisory to intensive assistance. Equipment and devices are also provided to assist the resident, or provide alerts to staff. These range from walkers and medication reminders to emergency alert systems. For persons residing at home, there may be modifications to the home such as ramps, grab bars, and special door handles.

Individuals require social, physical, and intellectual involvement and challenges in order to maintain or enhance their level of functioning at optimal levels. Thus, the setting in which the individual resides must afford as much activity and freedom as possible, within the capacities of the individual. Additionally, it must be designed to incorporate relevant programming in the form of social activities, the availability of appropriate equipment and transportation, and staff with the right training and temperament. Policies and arrangements of long-term care facilities contain details for such arrangements, and the laws and regulations affecting such facilities require this. Case managers, regulators, and auditors provide corrective feedback and actions to ensure that these facilities are compliant. 

Family and other caretakers: Surveys of long-term care tell us that family members provide the lion's share of long-term care services. A smaller percentage of care is provided by informal, unpaid caregivers that have various types of relationships with the elderly individual. If such free care were paid for, it is estimated that it would amount to as much as $100 billion. Roughly 95% of non-institutionalized elders receive some level of support from family members. A good majority of them rely solely on this free help. The person providing the most support is referred to as the primary informal caregiver. Additional caregivers are called secondary informal caregivers. On the other hand, about half of the elderly who need long-term care, but who do not have family support available, live in nursing homes. Of those who do have such support, only 7% live in nursing homes. (National Academy on Aging, 1997)

Any number of emotional adjustment issues can arise in family members and the older individual in considering changes in living situation, even when it is nothing more than increased family involvement. People can be quite protective of their independence; particularly where there is not a strong history of open communication and collaboration between the elderly individual and the family members involved. Additionally, the elderly person is being pushed by circumstances to face limitations that may be difficult to accept or acknowledge to others.

Therapists or other professionals may help family members prepare for transitions effectively, and reduce family conflict that may be exacerbated by upcoming challenges.

Examples of Long-Term Care Facilities

Skilled Nursing Facilities: Also known by their acronym as SNFs (pronounced "sniffs"), these establishments are highly regulated, and provide various levels of personal and medical care and supervision. They also provide supervised activity. These are funded privately and, where there is eligibility, funded through Medicare.

Unfortunately, many SNFs are unpleasant, neglectful, or invasive environments. Staff may be neglectful of some residents. This is because they are placed under disproportionately great demands by the more impaired residents, and they have extensive documentation requirements. This can cause staff burnout, which results in excessive staff turnover. This means heightened risk for errors and abuse. Psychiatrists and other mental health providers may be scarce in some regions.

Residents are not always provided the level of care they need. This means that higher-function residents may find the more impaired residents vexing because of their noise-level, invasive or threatening behavior, and poor hygiene. The threat of drug-resistant infections plagues the facilities that provide care to residents most in need of medical care and who are bedridden.  Of course, the move to a populous facility in which there is so much less independence is a very demanding adjustment in itself. It is not possible to simply go to the kitchen and make a sandwich.

There is funding for mental health services when it is deemed necessary. This may require advocacy or additional coordination. In some regions, appropriately trained mental health professionals, particularly psychiatrists, can be scarce. This may be because of the poor funding levels that discourage many professionals from accepting Medicare patients or clients.

Hospice Care: This form of care is for individuals approaching the end of life, and for whom heroic medical efforts to prolong life are not desired or are not appropriate. One of the benefits of hospice care is that the emphasis is on emotional and physical comfort. The care provided is called palliative care. This is made possible by not emphasizing invasive medical treatment, and by cultivating a more pleasant environment.

Care is provided by a team of professionals such as nurses, nursing aides, social workers, counselors, chaplains, volunteers, and physicians. Each member of the team has various roles to play. Therapists and other professionals can gently and sensitively help older individuals and their families talk more comfortably about the realities of aging and end-of-life matters.

Because of their training and experience with end-of-life matters, staff at such facilities can provide very helpful consultation and medical care that is relevant to the needs and values of the elder. This includes bereavement support for family members.

Abuse and Neglect

Overview

Much caregiver distress, conflict, and even abuse occurs when family members do not have adequate skills or impulse control to meet the increasing challenge of coping with an elderly dependent whose behavior exhibits signs of dementia. Unsophisticated individuals may take the disorganized behavior of an elderly person personally, and this can create anger that the individual is not prepared to control. This disorganized behavior stemming from dementia can be difficult for most people to cope with, and may include perseveration, mishandling and misplacing important things, saying disturbing things, and even being threatening or violent. Caretakers may already be stretched to the limit by the demands of their role, and unable to handle increasing demands posed by worsening mental health or medical issues. Risk of abuse increases with age.

This dynamic may be amenable to mental health intervention.**fix in 3 unit Of course, moving the elderly person to a higher level of care or simply to a safe setting may be the only acceptable alternative. Determining the best course of action requires not only the clinician's mental health assessment, but also investigation by Adult Protective Services that includes input from other professionals, family members, or others involved with the situation. Factors that may be of importance in such an investigation include the wishes and competence of the elderly individual, the level and frequency of the abuse, indicators of whether the abuse is remediable, and whether the living situation would be appropriate were the abuse resolved.

According to the Administration on Aging (AOA, 2006), hundreds of thousands of elderly individuals experience abuse, neglect, or exploitation each year. Many of these individuals are dependent upon others and unable to effectively defend themselves or recognize exploitation. All 50 states have laws intended to prevent the abuse of elders.

Friedman, Avila, Tanouye, and Joseph (2011) provide the following statistics on elder abuse:

Researchers estimate that the prevalence of elder abuse in the United States ranges from 500,000 to 2.5 million individuals aged 60 and older. Based on national surveys, substantiated reports of elder abuse have been on the rise during the past 2 decades. Of the substantiated reports of abuse, the relationship of the perpetrator to the victim was most frequently adult child (32.6%) spouse or intimate partner (11.3%) and other family member (21.5%). An important risk factor associated with elder abuse is living with a primary caregiver but otherwise being socially isolated from other friends and family. In addition, the likelihood of violence by a caregiver appears to increase when the victim is violent or if the caregiver is the spouse or an intimate partner. Alcohol abuse by the perpetrator is also strongly associated with physical abuse.

The authors discuss alcohol abuse by the perpetrators:

Alcohol abuse by the perpetrator also plays a substantial role and is strongly associated with physical abuse, although there is little information regarding alcohol abuse by the victim. In one cross-sectional study of people with psychiatric illness, there was an insignificant positive association with alcohol abuse in the victim, although the sample size was small, which may have affected the statistical power of the analysis (sample of 20 victims; 3 experiencing physical abuse). Based on the narratives in the current study, it appears that, in many cases, the victim and perpetrator both consumed alcohol before the assault.

Reporting Abuse or Neglect of the Elderly

Mandated reporting: Laws on elder abuse reporting vary from state to state, but they have a great deal in common. Psychotherapists are among the individuals that are lawfully mandated reporters of elder abuse and neglect. Licensed therapists are legally required to report abuse, neglect, or exploitation that they have come to suspect abuse or neglect in the course or scope of their employment or professional capacity.

Reasonable suspicion does not require proof or any kind of investigation on the part of the mandated reporter. In fact, investigation should be left to the designated authorities. Essentially, reasonable suspicion means that the individual has a level of suspicion that is significant and reasonable, because of information, circumstances or observations. Mandated reporting includes injuries that may be indicative of abuse or neglect. What is reported may include acts or omissions. Generally, allegations are automatically mandated to report.

Reports should be made immediately. An agency cannot create rules that prevent or delay you in reporting. If another worker or your supervisor is involved and takes responsibility for reporting, you must directly confirm that the report is being made. If it is not made immediately, you must make it, regardless of others' roles, because you are a mandated reporter.

Failure to report is subject to criminal penalties and constitutes unprofessional conduct. There are legal protections against liability in many states, including California, for mandated reporters that are acting competently and that are not acting out of malice. In other words, the report is made in good faith. 

Elders are considered to be those aged 65 years or older.

False allegations: It is not possible to know how often false allegations of abuse occur, but they may arise from a family member or conservator that wants control over assets, among other things.

Sex: Although there is limited research on the subject, it is accepted that people can enjoy and engage in sexual activity well into older years, with no established upper "age limit." (Hyde, et al, 2010) It is important not to confuse sexual abuse with consensual sexual activity. In the absence of violence or coercion, there may be a question of competence. An aged individual that is highly impaired may be considered a victim on the basis that they are not considered capable of giving consent. This requires a substantial level of impairment.

Long-term facilities may interfere with sexuality between residents. They may have good intentions, but this amounts to abuse in cases of individuals that are able to give consent. There are many observations of long-term care staff perceiving their residents too much like children, and themselves too much like parents.

Sexually transmitted diseases (STDs) are requiring increasing attention from those working with the elderly and increased sexual education efforts as well. This is because of increased acceptance of sex in the elderly, increased divorce and partner change in the elderly, and with increased rates of survival of persons with HIV infections. (Minichiello, Hawkes, & Pitts, 2011) 

Uncertainty: If you are unsure as to whether a suspicion is reportable, you can contact the agency responsible for taking such reports and discuss the details in a manner that does not violate confidentiality. If you decide to report, then you can provide identifying information. It is important not to report suspicion simply become one feels suspicious. One must be able to identify one or more specific causes for suspicion.

Dependent adults: Many care facilities combine elders and non-elders. Abuse of non-elder dependent adults is also a mandated reporting situation. Reporting of allegations is not required when there is a lack of credibility due to, for example, compromised mental functioning and repeated baseless allegations. The specific laws pertaining to reporting vary from state to state, but this section will cover helpful points that are universal, or nearly so, among the states.

Credibility: Because there are false allegations of abuse or neglect by persons with psychiatric problems, there are legal exceptions to reporting when there is a lack of credibility. This is most applicable in cases of clients that make repeated or random allegations that are unsubstantiated. These situations are easiest to identify when the claim lacks credibility, as when an alleged knife attack has produce no injuries. However, it is certainly true that individuals who are compromised are often subject to abuse or neglect. Thus, an allegation should not be written off exclusively because the individual making the allegation is compromised.

Preparation: The therapist should have information available when reporting, but this should be handled immediately. The disabilities and medical status of the person is relevant to the work of these agencies and should be shared. This includes factors such as confusion or memory loss. The agency needs to know what social support or other professional or agency involvement is available and its status. The therapist should review with the agency the observations noted, including when they occurred, who was involved, and what happened. This should include any observations such as bruises or neglectful or dangerous conditions. Individuals who are not mandated reporters may report anonymously.

Suspicion of abuse in long-term care facilities is reported to the Long-Term Care Ombudsman, www.aoa.gov

See the Resources section for additional information and assistance. 

Confidentiality Issues in Elder Abuse and Neglect

Confidentiality is treated in some detail in federal and state law, as well as in professional ethical standards such as the NASW Code of Ethics, The provision of information regarding confidentiality is an important part of informed consent. In family therapy, all competent parties must have informed consent. Ethical codes and federal HIPAA law specifically address informed consent.

In geriatric care, it can be difficult to navigate confidentiality issues because of family members feeling entitled to information. Their caretaking roles and the childlike vulnerability of the older person can understandably lend to this feeling. If the older person has become unduly suspicious, they may interfere with their own well being be restricting access to their personal health information.

The therapist's duty to protect confidentiality persists after the death of the client, although the therapist has a duty to report information supporting a reasonable suspicion that the death resulted from a crime. The client's legal representative is responsible for making decisions regarding confidentiality after the client's death, with exceptions established in law.

Level of Care in Abuse/Neglect Dynamics

Older persons may be placed at too low a level of care for their needs. Level of care refers to factors such as staff to resident ratio, the availability of mental health professionals and medical staff, and other factors relevant to care needs.

Families and caretakers in informal or home arrangements may be unable to provide the proper level of care, or may have one or more family members that abuse the older person. Below, we provide a bullet point view of level of care issues as an aspect of abuse and neglect that is drawn from numerous sources.

Dynamics of abuse and neglect:

Inadequate supervision

Attempts to control the older person by an untrained person resulting in accidental injuries

Mismanagement of medications or medical equipment

Inadequate activity that results in medical problems or decreased mental capacity

Inadequate care that results in medical problems (e.g., bed sores) and increased dependence

Why does this happen?

Families and caretakers may already be highly stressed by the physical and emotional demands of caretaking. Additional stress, including changes in the needs of their charge may result in abuse or neglect.

Caretakers may be incompetent to handle the level of care needed because they are incompetent or impaired, or because the level of care requires more people or professional skill or equipment.

They may be unable to tolerate the stress of the older person's behavior, particularly when there are mental health problems such as dementia. For example, disorganized behavior stemming from dementia can be difficult for most people to cope with, and may include perseveration, mishandling and misplacing important things, saying disturbing things, and even being threatening or violent.

They may not be able to afford the physical accommodations needed for adequate accessibility. This restricts the older person's ability to move or use the facilities of the house, limiting their activity. It also imposes a greater demand for assistance upon caretakers.

Families and caretakers may be slow or unwilling to arrange for a higher level of care, through, for example, transfer to a long-term care facility.

Why does this happen?

They may feel guilt.

They may not trust facilities. This may be because of the actual risks, because of stories they have heard or experiences they have had, or because of excessive fear that is a reaction to letting go.

There may be financial problems or limitations, insurance or other benefit denials, or too much time elapsing during attempts to gain funding or to mount appeals.

There may be a lack of appropriate facilities. The family may be resistant to moving their charge to a distant facility because of their desire to monitor and help, and their desire to be close to their loved one.

The older family members needs (e.g., functional level or behavior problems) may change too rapidly for the family's ability to respond and change the level of care.

Highlight on Two Types of Abuse and Neglect: Exploitation and Severe, Traumatic

Laws and regulations define types of abuse that generally fall into the categories of physical, emotional, fiduciary, and sexual abuse.

Fiduciary abuse or other exploitation: Using or appropriating the elder's resources through manipulation or other illegal means. Most of the financial damage by this kind of abuse is usually caused well before it is detected or can be stopped. An exploitive family member or other person that has gained the older individual's trust usually perpetrates this kind of abuse. They take advantage of the older person’s impaired judgement and memory, as well as loneliness and vulnerability.

Severe, traumatic abuse: The literature on severe traumatic elder abuse is very limited. Friedman, Avila, Tanouye, and Joseph (2011) state that, according to their research, “victims of severe traumatic elder abuse were more likely to be female, to have a neurological or mental disorder, and to abuse drugs or alcohol. The victims of abuse were assaulted with a wide array of weapons and predominately suffered injuries to the head and torso, suggesting an intent to kill—not injure. No firearms were used, although persons who die at the scene are less likely to be sent to a trauma unit, and firearms have a higher lethality.”

Appendix: Resources

PsychIN Directory

For a large listing maintained by the author, see www.PsychInnovations.com/directory/aging

Specific to Long-Term Care

The Eldercare Locator

www.eldercare.gov

1-800-677-1116

California State Website on Aging and Care

www.aging.state.ca.us

See the ombudsman program and other resources.

Milbank Memorial Fund

Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the Twenty-First Century

www.milbank.org/0008stone

The National Hospice and Palliative Care Organization

www.nhpco.org

Resources and Information for the Elderly and Caregivers

Administration on Aging (U.S., HHS)

http://www.aoa.gov/

Links to resources and programs, coverage of statistics, relevant articles, etc.

Help Guide to Mental Health and Lifelong Wellness

www.helpguide.org/elder_care.htm

National Senior Citizens Law Center

www.nsclc.org/

Errold F. Moody

www.efmoody.com

This website provides information and links to a comprehensive array of information regarding care for the elderly and those that care for them.

CDC: Healthy Aging

http://www.cdc.gov/aging

End of Life Toolkit (Florida Hospital Association)

http://www.fha.org/endoflife/endoflifetoolkit.html

Numerous materials on various topics

Elder Abuse Resources

National Center on Elder Abuse website (includes a hotline section for reporting)

http://ncea.aoa.gov

Long-Term Care Ombudsman

www.aoa.gov

Suspicion of abuse in long-term care facilities is reported there.

National Center on Elder Abuse Hotline

http://ncea.aoa.gov

Age  & Opportunity Older Victim Services and Support

http://www.ageopportunity.mb.ca/htmlfiles/VOLUNTEER_OPPORTUNITIES/older_victim_services_program_support.asp

The OVS Program Support Volunteer provides emotional support to older adults who have  experienced some form of criminal victimization as well as providing  information and assistance when required.

American Administration on Aging: Elder Rights/Elder Abuse

http://www.aoa.gov/eldfam/Elder_Rights/Elder_Rights.asp

A wealth of information on elder abuse research, prevention, education, victim support, resources and reporting.  Highly recommended.

American Administration on Aging Elder Abuse Factsheet

http://www.aoa.dhhs.gov/press/fact/alpha/fact_elder_abuse.asp

This page explains exactly what elder abuse is, how to recognize and where to go for help.

Elder Abuse

http://www.wordbridges.net/elderabuse/

Extensive information on elder abuse, training for professionals dealing with such abuse,  research in the field, legislation (US), as well as a monthly online review of  articles, news and other information on this subject.

International Network for the Prevention of Elder Abuse

http://www.inpea.net/

The International Network for the Prevention of Elder Abuse aims to increase society's ability, through international collaboration, to recognize and respond to the mistreatment of older people in whatever setting it occurs, so that the latter years of life will be free from abuse, neglect and exploitation.

National Center on Elder Abuse. An excellent resource on elder abuse, how to help, where to go for aid, research and documentation, conferences, newsletters and their

http://www..udel.edu/cane/IntroAll.jsp

Clearinghouse on Abuse and Neglect of the Elderly (CANE)

Citations

Administration on Aging. (2011). A profile of older Americans: 2010. Accessed from http://www.aoa.gov/aoaroot/aging_statistics/Profile/2010/2.aspx

Administration on Aging. (2006). Elder Abuse. Accessed from http://www.aoa.gov/

Administration on Aging. (2005). Older americans 2004: Key indicators of well being

Administration on Aging. (1998). National elder abuse incidence study.

Alexopoulos, G. S., Katz, I. R., Reynolds, C. F. III, Ross, R. (2001). Depression in older adults: A guide for patients and families. Expert Knowledge Systems, L.L.C., and Comprehensive NeuroScience, Inc. Accessed from  http://www.psychguides.com/Geriatric%20Depression%20LP%20Guide.pdf

Cassels, C. (2011). Has the silver tsunami begun? Medscape Medical News from: The American Psychiatric Association's 2011 Annual Meeting.

Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, National Health Interview Survey (2002) as found in Federal Interagency Forum on Aging-Related Statistics: Older Americans 2004: Key Indicators of Well Being from http://agingstats.gov/ (June 2005)

D'Aprix, A., and Alexander, M. (2011). Long-Distance Caregiving.  American Society on Aging: Long-Distance Caregiving Webinar Series. Accessed from

Detering KM et al. The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ 2010 Mar 23; 340:c1345

Doty, P. (2000). Cost-effectiveness of home and community-based long-term care services. Washington, DC: U.S. Department of Health and Human Services: Office of Disability, Aging and Long-Term Care Policy.

Hyde, Z., et al. (2010). Prevalence of Sexual Activity and Associated Factors in Men Aged 75 to 95 Years, A Cohort Study. Annals of Internal Medicine, 153(11). 693-702. Accessed from http://www.annals.org/content/153/11/693.abstract

Minichiello, V., Hawkes, G., and Pitts, M. (2011). HIV, sexually transmitted infections, and sexuality in later life. Current Infectious Disease Reports, 13(2), 182-187. doi: 10.1007/s11908-010-0164-6

Mueller, P. S. (2001). Facilitated advance care planning improves end-of-life care in elders. Journal Watch, June 7.

Fentleman, D. L., Smith, J. and Peterson, J. (1990). Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes (Eds.). Successful aging: Perspectives from the behavioral sciences.

Friedman, L. S., Avila, S., Tanouye, K. and Joseph, K. (2011). A Case–Control Study of Severe Physical Abuse of Older Adults. Journal of the American Geriatrics Society,59(3), 417-422.

Kaufman, L. (2008). A Superhighway to Bliss. The New York Times, 5/25.

Komisar, H. and Thompson, L. (2004). Who pays for long-term care? Fact Sheet, Long-Term Care Financing Project. Washington, DC: Georgetown University Press.

Lavretsky, H. (2011). Spirituality and aging in modern society. Aging Health, 6(6), 749-769. American Psychiatric Association (APA) 2011 Annual Meeting. NR08-42, May 17. Accessed at: http://www.medscape.com/viewarticle/740654_2

Mather, M., and Carstensen, L. L. (2005). Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences

National Academy on Aging. (1997). Facts on long-term care. Washington, D.C. Accessed from http://geron.org/NAA/ltc.html

National Senior Citizens Law Center. (2011). LGBT older adults in long-term care facilities: Stories from the field. Washington, DC. Accessed at: http://www.nsclc.org/abou t-us/nsclc-in-the-news/ns clcnews.2011-04-26.907258 4672

President's Council on Bioethics: Aging and End-of-Life. (2004a). Bioethical Issues of Aging I: Dementia and Human Personhood. Apr. 4. Accessed from http://bioethics.georgetown.edu/pcbe/transcripts/april04/session5.html

President's Council on Bioethics: Aging and End-of-Life. (2004b). Aging and care-giving: Options for decision-making. Dec. 2. Accessed at: http://bioethics.georgetown.edu/pcbe/topics/end_of_life_index.html

Stone, R. I. (2000). Long- term care for the elderly with disabilities: Current policy, emerging trends, and implications for the twenty-first century. Milbank Memorial Fund.