«WHAT PRACTITIONERS SHOULD KNOW ABOUT WORKING WITH OLDER ADULTS NORMAN ABELES, PHD President, American Psychological Association APA Working Group on ...»
Although few studies have formally examined its efficacy in older adults, couples therapy may be an effective treatment for late-life marital or partner problems. Issues of concern raised by older adults include long-standing interpersonal differences or difficulties that arise in the context of late-life stress (e.g., one partner’s physical decline and increasing dependency).
Since family members often play an instrumental role in bringing older adults for psychological treatment in many settings, coordination with them is important. Although most theories or research studies of family therapy do not address the late-life family, family intervention may be indicated. Because of practical problems in assembling several geographically dispersed family members with competing role responsibilities (typically children), family therapy with the elderly is often dyadic (e.g., an adult child and older adult).
Psychoeducational approaches developed particularly for family members caring for older adults with cognitive loss may be useful in helping them more successfully care for the impaired relative. Education about the nature of cognitive loss, problem-solving practical problems, and the provision of emotional support are key components of such psychoeducation. A similar psychoeducational approach may be useful for relatives caring for older adults with depressive or anxiety disorders.
For older adults experiencing significant cognitive loss, cognitive training techniques, behavior modification, and changes in the social or physical environment may lead to improved emotional health and functioning.
Since many people experience a diminishing of select mental abilities as they age (also called age-consistent memory decline), older adults may benefit from interventions to enhance mental performance.
WHAT OTHER INTERVENTIONS MAY BE USEFUL FOR OLDER ADULTS?
Other psychologically informed approaches exist to treat late-life problems or to enhance the quality of later life.
Some have observed that older people may find it beneficial to engage in reminiscence or “life review,” in which past problems and successes are the focus of reflection. The goal of such an effort is to help the older person to reckon more fully with the many threads of a person’s own course of adult development, with the desired result of greater psychological integration and emotional resiliency.
Mutual aid support groups exist for persons facing a variety of life difficulties. For older people receiving psychological treatments, they may be a useful adjunct. For example, in many regions of the country, support groups exist for family members caring for persons with Alzheimer’s Disease and for persons contending with the major medical illnesses evident in late life (e.g., Parkinson’s Disease, cardiac problems, arthritis, cancer).
Focused efforts to facilitate grief or bereavement may be especially helpful for older adults experiencing issues of unresolved loss or contending with multiple losses.
Mood and memory workshops may improve functioning and are effective for properly trained psychologists to use. In addition, regular mood and memory checkups for older adults can be encouraged, just as we now encourage physical health checkups. Although age-consistent memory changes and mild depressive symptoms may be common and not severe, the discomfort they can cause should not be overlooked or downplayed. These problems may be appropriate targets for psychological intervention, much as hearing and vision loss in older adults, while common and not necessarily severe, are routinely treated with assistive devices or other interventions.
REGULAR MOOD AND MEMORY CHECKUPS FOR OLDER ADULTSCAN BE ENCOURAGED… There are psychologically beneficial aspects of exercise for older adults.
Social and educational programs such as classes, travel, elder hostels, and volunteer work can promote socialization and social support among older people.
WHAT ADAPTATIONS OF PSYCHOLOGICAL INTERVENTIONS ARE REQUIRED FOR OLDER ADULTS?
In addition to the general principles of working with older adults outlined earlier, several adaptations of existing psychological interventions may be helpful.
The processes of problem-solving, learning, and behavior change may evolve more slowly for older adults.
Written materials that are typically part of cognitive-behavioral interventions need to be presented in a manner that is understandable to most older people and printed in type large enough so that adults with visual impairment can read them.
Cognitive impairment in an older client is not necessarily a contraindication to receiving psychological treatment. Although older clients must have the capacity to interact with the psychologist, understand what is discussed in therapeutic sessions, and retain the basic issues and themes of the psychotherapy, older people with mild and even moderate cognitive loss may benefit from psychotherapy. In the case of cognitively impaired older adults, interpersonal support and environmental/behavioral modification may play a greater role than with other older people.
Many late-life mental disorders are recurrent or chronic. The psychologist needs to be flexible about setting therapeutic goals. Goals may emphasize managing symptoms, preventing relapse, and enhancing functional capacity rather than completely ameliorating presenting problems.
HOW DOES DELIVERY OF PSYCHOLOGICAL SERVICES TO OLDER PEOPLE DIFFER ACCORDING TO THE
SETTING WHERE THE OLDER PERSON RECEIVES THEM?
Psychological services may be provided to older adults in a wide range of locations including in their own homes; outpatient and inpatient medical, rehabilitative, or psychiatric settings; adult homes (also referred to as board-and-care facilities); senior centers; day care centers; and nursing homes. For some settings, specific issues must be addressed when delivering services.
Psychologists who see older clients within an independent practice or outpatient mental health settings need to be flexible about missed or rescheduled appointments. This is required because of acute medical crises, responsibility for care of infirm relatives, or the understandable reluctance of many older people to travel during inclement weather.
Close and timely coordination with other professionals is particularly important when providing psychological treatment to older people in inpatient medical, rehabilitation, or psychiatric settings where increasingly there are abbreviated lengths of stay.
There has been a significant increase in the delivery of mental health services by psychologists in nursing homes. Nursing home clients perhaps present the greatest challenges for psychologists of all older adults seeking psychological services.
Usually nursing home clients are physically frail and have cognitive deficits. This requires the psychologist to be especially flexible and creative about adapting psychological interventions so that they are most useful to the client.
Because psychologists sometimes work for nursing homes or depend on the cooperation of their administrators to deliver services there, sometimes they are pressured to act in ways that may not always be in the older client’s best interests (e.g., silence an angry and complaining older client who may have legitimate concerns about the quality of care that is being received). Maintaining clarity that the client’s interests are foremost is consistent with ethical principles.
Privacy of psychotherapeutic sessions may require considerable effort, because older residents often have roommates, and finding a quiet, separate place to talk may be difficult. The psychologist must make certain that the client consents to sharing the contents of any psychotherapeutic session with other staff.
Since the nursing home is indeed the older client’s home, environmental and interpersonal issues may have an important influence on the client’s emotional well-being. Interventions made on behalf of the client are sometimes necessarily those that seek to change institutional routines, reduce environmental stresses, and decrease maladaptive behavior on the part of staff toward the patient. In view of these issues, collaboration and coordination with nursing home staff are critical. (See Standards for Psychological Services in Long-Term Care Facilities for a more detailed account of these issues.)
WHAT OTHER ROLES CAN PSYCHOLOGISTS PLAY TO IMPROVE THE PSYCHOLOGICAL WELL-BEING OFOLDER ADULTS?
Although providing direct services to older adults is the chief focus of professional psychologists, there are other activities that may enhance the well-being of older people.
VII. BROAD PROFESSIONAL ISSUES OF CONCERN TO PSYCHOLOGISTS
WORKING WITH OLDER ADULTSA number of issues crosscut the specific topics that have been previously discussed. They encompass practical topics, including sources of reimbursement for psychological services, the need for interdisciplinary collaboration in providing services to older people, and awareness of the realities of older adults from racial or ethnic minority groups and other special populations. There are also specific ethical challenges in working with this age group. Finally, psychologists can play a role in educating the larger community about mental health/behavioral health care and aging, supervising and collaborating with colleagues and other professionals, and participating in the shaping of public policy in this area.
HOW ARE MENTAL HEALTH SERVICES TO OLDER ADULTS REIMBURSED?
Directly or indirectly, most mental health services to older adults are reimbursed through one or more sources of public funding, notably Medicare, Medicaid, and the U.S. Department of Veterans Affairs. Local, county, and state initiatives exist in some parts of the country to enhance the scope or quality of mental health services to older people. Some older people purchase additional private insurance, typically to supplement Medicare reimbursement, and others are dually eligible for Medicare, Medicaid, or veterans’ benefits.
In 1987 psychologists (as well as social workers) were designated as Medicare providers, which has enabled psychologists to provide fee-for-service assessment and treatment to older adults. Under this arrangement most services are reimbursed at 50 percent of fees established by Medicare.
Since the designation of psychologists as Medicare providers, there has been considerable expansion of mental health services into nursing homes and other residential facilities. While provision of psychological services to this population is a welcome development, reimbursement of these services has recently come under sharp scrutiny by Medicare, which has raised questions about the appropriateness of some of the services that have been delivered.
Increasing numbers of older people are entering managed care delivery systems, including health maintenance organizations (HMOs). HMOs provide the potential for better integrated systems of care than exist in many sectors, yet there is ongoing concern about the level of mental health services that are available within them, especially to those older persons with chronic and persistent mental illness.
WHY IS MULTIDISCIPLINARY/INTERDISCIPLINARY COLLABORATION SO IMPORTANT IN WORKING WITHOLDER ADULTS?
As previously noted, many older adults seeking psychological services have concurrent medical problems.
Some have more than one mental disorder or coexisting social problems. Initial and ongoing collaboration with other health care professionals and family members is critical for the accurate assessment and treatment of older adults. The most tightly integrated form of collaboration is an interdisciplinary treatment team which sets team goals, develops joint treatment plans, and addresses team process and content issues.
In outpatient settings, collaboration with the client’s primary health care provider may be critical to understanding whether initial psychological symptoms and acute changes in the client’s mental status have a medical component. For older clients in need of psychotropic medication, a good working relationship with a psychiatrist may increase the likelihood that psychological symptoms improve and that medication side effects are addressed. Social workers can play a vital role in assuring that the older client and family are knowledgeable of financial entitlements and community resources that may improve the quality of life.
In nursing homes or in adult homes/board and care facilities, collaboration with resident staff and those who provide onsite health care services will expand the psychologist’s understanding of the older client’s day-to-day functioning, as well as provide opportunities to address environmental issues that may adversely affect the mental and social well-being of the older resident.
WHAT ARE ISSUES OF CONCERN IN DELIVERING SERVICES TO MINORITY OLDER ADULTS AND OTHER
When working with older adults, it is important to keep in mind the singular experiences of special populations, including racial and ethnic minorities and older gay men and lesbians. In addition to the unique historical experiences that have affected the lives of the larger cohort of older adults, life histories of ethnic and racial minority older people have been further shaped by their prior and current status in the society. As an example, Blacks in this older adult age group spent much of their lives receiving separate, but not always equal, segregated health services. These experiences will often influence health-related attitudes and behaviors in the present.
WHAT ARE SOME BASIC FACTS ABOUT ETHNIC AND MINORITY AGING?
In the future, the older population will be much more racially and ethnically diverse. The current older population is predominantly White. However, by the middle of the next century, the number of older Black persons will more than triple, increasing their proportion of the total older adult population from 8 to 10 percent. More dramatically, the Hispanic population will increase nearly 11 fold, rising from less than 4 percent of today’s older adults to nearly 16 percent.