«WHAT PRACTITIONERS SHOULD KNOW ABOUT WORKING WITH OLDER ADULTS NORMAN ABELES, PHD President, American Psychological Association APA Working Group on ...»
Sleep problems increase with age, and about half of people over age 80 complain of a sleep difficulty.
Insomnia is a common complaint among older adults, but hypersomnia is uncommon. Hypersomnia is characterized by excessive daytime sleepiness or prolonged periods of sleep. It does not refer to the naps that older adults often take.
Because older people may not need to adhere to a daily schedule, they are more likely to experience sleepwake schedule problems. These disorders involve a lack of synchrony between the actual times the individual is asleep and awake, and the body’s natural circadian rhythm.
Sleep apnea, episodes during which breathing stops briefly during sleep, increases with age and is a common problem among older adults. Severe apnea may be particularly dangerous because it can trigger rhythm problems of the heart, lead to increased blood pressure, and result in decreased cognitive functioning.
Periodic leg movements may also cause sleep disturbances in later adulthood. This twitching of the legs during sleep usually occurs earlier in the night and lasts from a few minutes to a few hours, often causing the individual to get out of bed repeatedly to relieve the discomfort.
SOMATOFORM DISORDERSHypochondriasis is the somatoform disorder most likely to be found in later adulthood. From 10 to 15 percent of older adults exhibit a marked concern about their health and overestimate their level of physical impairment. Hypochondriasis may exist alone or coexist with a number of other disorders, such as depression, anxiety, and dementia.
Older adults with somatoform disorders are at risk for lack of appropriate attention from health care professionals who may minimize symptoms of real physical disorders. Those with somatoform disorders are also more likely to take unnecessary medications and to undergo unnecessary medical procedures, both of which are especially risky for them and may contribute to actual morbidity.
…DREAM SLEEP DECLINES FROM 40 PERCENT OF
SLEEP TIME IN EARLYCHILDHOOD TO ABOUT 25 PERCENT BY AGE 70.
SUBSTANCE USE/ABUSE DISORDERSThe prevalence of alcohol abuse and dependence in adults 65 years of age and older ranges from 2–5 percent for men and about 1 percent for women. There is a decline in substance abuse for adults over age 60 years.
Risk factors for alcohol abuse among all adults include genetic predisposition, being male, limited education, low income, and a history of psychiatric disorders, especially depression.
Stressors are more important contributors to late onset alcohol and drug abuse than to early onset abuse.
Common stressors that contribute to alcohol and drug abuse in later adulthood include retirement, relocation, death of a spouse or close relative, conflict within the family, financial concerns, and physical health problems.
Older widowers have the highest prevalence rates of alcohol abuse among older adults.
Regular alcohol consumption may lead to other medical problems for older adults because of the physiological changes that accompany aging. A major problem for older adults who consume excess alcohol is malnutrition, because they may fail to eat a balanced diet.
Another alcohol-related problem is osteomalacia, or thinning of the bones.
Excess alcohol intake is also related to a decrease in the ability of the stomach to absorb food.
The most frequent and serious problem with chronic alcohol use in older adulthood is a decline in cognitive functioning. Chronic alcohol abuse may lead to major declines in memory and information processing.
EXCESS ALCOHOL CONSUMPTION MAY LEAD
TO CIRRHOSIS OF THE LIVER, ONE OF THE EIGHT
LEADING CAUSES OF DEATH IN OLDER ADULTS.
The abuse of drugs by older adults typically takes the form of abuse of prescription medications, tranquilizers, and sedatives. One-fourth of medications used in this country are taken by adults over 65 years of age, including prescription drugs and over-the-counter medications. Some of the most commonly used drugs among older adults are tranquilizers and sleeping pills.
Because of physiological changes associated with aging, drug toxicity is more likely in later than in younger adulthood.
Combining alcohol and drugs, especially tranquilizers and sleeping pills, is especially dangerous, as there may be a cumulative depressant effect on the central nervous system.
OTHER PROBLEMS THAT MAY AFFECT OLDER ADULTSAdjustment Disorder. The most common stressor that leads to adjustment disorder in later life is physical illness. Other stressors which often precipitate adjustment disorders among older adults are those associated with late-life losses, e.g., relocation, retirement, financial problems, family problems, and lengthy hospitalization.
Personality Disorders (PDs). Most PDs, particularly those in Cluster B (i.e., Borderline, Narcissistic, Histrionic, and Antisocial) decline in frequency and intensity with age. However, PD presentation may take a modified form, and these “geriatric variants” are associated with difficulties in medical management and psychotherapeutic treatment. For example, the antisocial behavior of older adults may not be manifested in ways that lead to incarceration as with some younger persons with sociopathy, but may be exhibited as selfish, impulsive behavior towards community caregivers, resulting in abandonment of the older adults.
Bereavement. Most older adults experience the loss of loved ones including spouses, other family members, and friends. While bereavement is a normal reaction to loss, pathological grief may develop. Symptoms of pathological grief among older adults are essentially the same as those for younger adults and include extensive guilt and preoccupation with death, a pervasive sense of worthlessness, marked psychomotor retardation, and functional impairment. The length of time spent in grieving is culturally determined and is also a function of resources of the individual and the circumstances of the death. In the United States, grief usually requires about 2 years for completion, with a great deal of variation around this average.
Elder Abuse. Some older adults are vulnerable to mistreatment by spouses, adult children, grandchildren, and caregivers. Elder abuse is much more likely to occur when the older person is experiencing physical, emotional, or cognitive problems. In a recent study, about 3 percent of community residing older adults reported being abused, including physical abuse, neglect, and chronic verbal aggression. This figure probably underestimates the problem because older adults are less likely to report domestic abuse. Sexual abuse is the most underreported form of abuse among older adults.
Because medical practitioners may overlook signs of physical abuse (e.g., bruises or other injuries) or assume they are because of falls, it is important for the mental health professional to question the cause of physical injuries. Most reports involve abuse committed by one spouse against another, sometimes in retaliation for lifelong patterns of abuse. This type of abuse is followed in frequency by an adult child abusing a parent. In comparison to younger individuals, older husbands are abused twice as often as older wives, and the abusers usually are dependent on the person they abuse. Patients with Alzheimer’s Disease and other dementing disorders are at greater risk for elder abuse. Late onset spousal abuse is related to substance abuse and psychopathology of both the abused and the abuser. Elder abuse occurs at all economic levels and among all age groups in later adulthood. When abuse occurs in the home, reporting is mandatory in many states by health care, social service, or other professionals who become aware of it. All states require reporting when abuse occurs in an institution. Psychologists working with older adults should be knowledgeable about applicable state laws on reporting elder abuse.
Age-Related Cognitive Decline. DSM-IV now lists this category (coded 780.9) under “Other Conditions That May Be a Focus of Clinical Attention.” It refers to an objectively identified decline in cognitive functioning consequent to the aging process that is within normal limits given the person’s age, and it is not attributable to a specific mental disorder or neurological condition.
V. ASSESSMENT OF OLDER ADULTS
WHAT ARE BASIC PRINCIPLES IN THE ASSESSMENT OF OLDER ADULTS?
In view of the physical, cognitive, and sensory changes often accompanying aging, the testing environment should be modified to assure optimal performance. The psychologist must be flexible in the testing process and in the interpretation of results. Qualitative indices are, at times, of more importance than quantitative indices.
The following accommodations may be necessary according to the unique characteristics of the older individual being tested.
Familiarize the older adult with the purpose and procedures of testing. Older adults, especially those with little formal education, are often less familiar with testing than younger adults and may be more cautious in responding. The psychologist should pay particular attention to achieving fully informed consent from the older adult or significant other.
Ensure optimal performance. Older adults should be prepared in advance for testing. They should be given prior notice to bring all assistive devices (e.g., hearing aids, eyeglasses).
If English is not the primary language or is not well understood, the validity of the testing may be in doubt.
If the tester is not bilingual, use an interpreter, preferably one whose expertise reflects both the specific language need and psychological training. The psychologist should be aware of how language problems can adversely affect test results.
Create a well-lighted and quiet environment. Glare should be minimized. Arrange the space to accommodate a wheelchair or other device for those with physical limitations.
Preferably use tests that have been constructed specifically for older adults. Most commonly used psychological tests have not been developed for use with older people, although some have age-related norms.
Ensure that the older adult understands the test instructions. Speak in clear, simple language but do not shout. Query and repeat if necessary. If needed, use large print materials.
Determine if the older adult patient is experiencing pain or discomfort and attempt to reduce it when possible. Find out what medication(s) the patient is taking and assess effect on performance.
Adjust the testing time to suit the optimal functioning of the older adult. Older adults tire more easily than younger adults. Plan for frequent rest and bathroom breaks. If fatigue sets in, resume testing at another time.
Use encouragement and verbal reinforcement liberally when testing.
Utilize multiple testing sessions to gauge how the older adult performs at varied times of the day.
WHAT ARE THE UNIQUE FEATURES OF A DIAGNOSTIC INTERVIEW WITH AN OLDER ADULT?
The diagnostic interview is a primary psychological assessment approach. Prior to a formal interview, the client or the client’s legally designated guardian must give informed consent. The client or the client’s guardian must understand the rationale for the testing, as well as how the findings may be utilized. Even with the consent of a legally designated guardian, obtaining the client’s consent is essential to obtaining reliable and valid findings.
Current mental status, the event precipitating the request for an evaluation, prior psychiatric history, and likely psychiatric diagnosis should be elicited. Current psychological difficulties should be placed in the context of the older client’s values, beliefs, stage-of-life issues, education, culture, and ethnicity.
Social aspects of the client’s problems should also be assessed. The presence of recent losses, adverse living conditions, financial stressors, pending legal matters, and family/interpersonal difficulties should be evaluated.
Information on the older client’s medical status is critical, because some psychiatric symptoms may be secondary to medical problems. Specifically, the following should be documented: current medical problems; past major medical problems; prescriptions and over-the-counter medications; current and past use of alcohol, tobacco, and nonprescribed drugs.
Noncompliance with prescribed treatment regimens should be ascertained. Acute psychological changes possibly related to initiation or discontinuation of medical treatments should be noted.
If cognitive impairment is suspected, diagnostic interviews with older clients should be supplemented, if at all possible, by interviews with family members or friends to determine convergence and discrepancies between information sources.
One widely used brief screening measure specifically developed for the older age group is the Mini-Mental State Examination (MMSE). It is easy to administer and includes verbal and nonverbal items. The MMSE and other brief cognitive screening tools are not diagnostic, and they should not be used as stand-alone diagnostic tests.
A major problem with most screening tests is that more subtle cognitive problems may not be detected. In addition, a poor score on a screening test does not indicate which of a large number of potential causes is responsible for the impairment. If screening or other history suggests cognitive impairment, then further evaluation including differential diagnosis may be necessary.