«WHAT PRACTITIONERS SHOULD KNOW ABOUT WORKING WITH OLDER ADULTS NORMAN ABELES, PHD President, American Psychological Association APA Working Group on ...»
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Achieving a healthier America depends on significant improvements in the health of those who are at highest risk of premature death, disease, and disability, which include many minority older people. Poor income and low literacy, which are associated with minority status, are important risk factors for the major chronic illnesses. For example, the risk of death from heart disease is more than 25 percent higher for low income people than it is for the overall population. People in families with incomes of less than $13,000 a year are twice as likely as the total population to be limited in major activities of daily living because of health. Activity of daily living limitations are 4 times more common among people with 8 or fewer years of education than among those with 16 years or more.
There is a robust correlation between lower educational attainment and low income. The fastest growing group of older Americans are the poor and the octogenarians (ages 85+ years). These groups use a higher percentage of the overall health budget and have longer hospital stays and more physician visits.
Each minority group of older adults has a unique history which, in many cases, has been influenced by discrimination. There are, of course, many differences among individuals within each group.
WHAT HEALTH-RELATED INFORMATION IS IMPORTANT TO KNOW IN DELIVERING SERVICES TO OLDER
MINORITY GROUP INDIVIDUALS?
The onset of chronic illness is usually earlier than in White older adults.
There are frequent delays in seeking health-related treatments.
Problems are underreported to health care providers or only conveyed to them in generalities until trust is established.
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There are high rates of noncompliance with medical regimens and treatment dropout.
There is evidence of increased tolerance to illness/disorder/discomfort to which individuals have adapted.
Although longevity for Black older men is shorter than for White older adults, after age 75 Blacks live longer than Whites (“racial crossover”).
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A sizable number of minority older adults do not qualify for Medicaid in some states.
Minority older adults frequently have been excluded from drug research.
Factors contributing to poor mental health include: poverty, segregated and disorganized communities, poor quality of education, few role responsibilities, sporadic and chronic unemployment, stereotyping, discrimination, and poor health care.
Access to mental health care is problematic for many minority older persons because up to 40 percent of psychiatrists will not accept Medicaid patients.
As with the majority of older adults, chief providers of mental health services are more likely to be primary health care physicians (nonpsychiatrists).
There is frequent misdiagnosis. For example, an older Black man may act suspiciously toward White mental health care staff who might interpret this as paranoia, without taking into consideration past adverse experiences with health care providers.
There is overrepresentation in state mental hospitals.
Some minority older adults use dual systems of care in which other approaches to health care augment Western approaches. Knowledge of dual systems of health care is important because minority older people may not readily accept traditional western formulations of their problems. They may be wary of interventions that do not make sense within their belief system.
WHAT ARE SOME ISSUES IN THE ASSESSMENT OF MINORITY OLDER ADULTS?
Few assessment instruments have been normed on minority older adults, which raises caution about interpretation of test findings in these groups.
Assessment of minority older adults should take into account literacy and fluency in speaking and understanding English.
Notably, instruments have been developed, for example, to assess mental status, depression, dementia, and pain in ethnic minority individuals.
WHAT ARE SPECIAL ETHICAL ISSUES IN DELIVERING PSYCHOLOGICAL SERVICES TO OLDER ADULTS?
Working with older adults may present special challenges to the psychologist. This is because older adults receive care from overlapping and not always well-integrated health systems. For some adults with chronic illness, both family members and paid caregivers are involved. In some settings (e.g., nursing homes, adult homes, board and care facilities), older adults both live and receive care in the same facility. With late life also comes increasing risk of severe physical debilitation and death. Because of these factors, there are particular ethical issues pertaining to confidentiality and end-of-life decisionmaking for professionals working with older adults.
APA’s Ethical Principles of Psychologists and Code of Conduct provides a framework for understanding central issues on the ethical treatment of older and younger clients. With older adults, however, issues arise that require careful evaluation and application of those principles.
It is important to note that unless declared incompetent, the older adult has a right to make decisions to initiate, withdraw, or terminate treatment. They have the right to personal autonomy and to refuse medications, surgery, and research participation.
In community settings adults, children, spouses, and other caregivers are frequently in contact with mental health professionals. To assure confidentiality, written permission should be obtained from older persons to communicate information regarding their status to relatives or to health care professionals.
For older persons with dementia, or other forms of significant cognitive impairment, confidentiality issues can become complex because questions may arise about the cognitively impaired older person’s ability to give truly informed consent to release information. Competency is a legal judgment, rules for which vary from state to state. However, if the older person is legally judged incompetent, then the appointed guardian is responsible for release of information. Some cognitively compromised persons have signed a document that grants permission to another individual, usually a spouse or adult child, to manage their affairs, in which case this is the person responsible for consent. In some cases the as yet legally competent older client may be willing to sign a consent form, yet the psychologist may have serious doubt about their ability to understand what is being requested. In this case, the psychologist must use best judgment guided by the principle that what is done is in the client’s best interest.
In nursing homes and assisted care facilities, some older clients whom the psychologist sees may be distressed over problems with the facility or staff. Some staff may request information from the psychologist to clarify the nature of the older client’s concerns and seek solutions to problems. Authorization to disclose information must be provided by the older client or guardian. Even if permission is granted, the psychologist must communicate only that information that is pertinent to the specific issue at hand.
The Patient Self-Determination Act of 1990 requires Medicaid and Medicare provider organizations to request at patient admission advanced directives from the client regarding termination of care. Another form of directive is the living will. The psychologist working with a severely ill older person may be part of a decisionmaking process that also includes family and medical personnel regarding end of life issues (e.g., whether or not to make extraordinary efforts to prolong the patient’s life). In these circumstances, the psychologist’s central task is to help patient and family better understand issues and options and help them to make value laden decisions without imposing the psychologist’s own views.
WHAT ARE LARGER ROLES THAT THE PSYCHOLOGIST WITH A PROFESSIONAL INTEREST IN OLDER ADULTS
Education. Psychologists can educate other professionals about the facts regarding normal aging, problems that some older adults encounter, and psychological interventions to address those problems. Educational efforts take place in a range of settings including the traditional classroom, institutional settings, continuing education offerings, professional meetings, media appearances, and during consultations or informal discussions with individual colleagues. There are also many opportunities for the education of family members, who provide 80 percent of all long-term care.
Advocacy. Psychologists may engage in a wide variety of advocacy efforts on behalf of older adults, especially those in need of mental health services. The focus of these activities may be directed at public policy on the local, state, or national level or in concert with the activities of professional organizations concerned with the social and emotional well-being of older people. The psychologist should respond to notices of proposed changes in mental health laws and rule making.
Research. Providing psychological services to older adults may present unique opportunities to initiate research studies or collaborate with those for whom research is their primary professional focus.
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