Ebersole and Hess' Gerontological Nursing & Healthy Aging in Canada 3rd Edition PDF

Ebersole and Hess' Gerontological Nursing & Healthy Aging in Canada 3rd Edition Veronique Boscart, Lynn McCleary, Linda Sheiban Taucar, Theris A. Touhy, Kathleen Jett  Chapter 23 Mental Health and Wellness in Later Life  Learning Objectives (1 of 2) Upo...

Ebersole and Hess' Gerontological Nursing & Healthy Aging in Canada 3rd Edition Veronique Boscart, Lynn McCleary, Linda Sheiban Taucar, Theris A. Touhy, Kathleen Jett  Chapter 23 Mental Health and Wellness in Later Life  Learning Objectives (1 of 2) Upon completion of this chapter, the reader will be able to: Discuss factors contributing to mental health and wellness in later life. List symptoms of late-life anxiety and depression, and discuss assessment, treatment, and nursing interventions. Recognize older adults who are at risk for suicide, and use appropriate techniques for suicide prevention, assessment, and intervention. Specify several indications of substance abuse disorder in older adults, and discuss appropriate nursing responses. 1-3  Learning Objectives (2 of 2) Upon completion of this chapter, the reader will be able to: Recognize signs of problem gambling and use appropriate techniques to screen for it. Provide culturally safe and competent mental health care to older adults. Evaluate interventions aimed at promoting mental health and wellness in older adults. 1-4 Mental Health and Mental Disorder in Later Life According to the World Health Organization (WHO, 2018), mental health is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Stress and Stressors The experience of stress is an internal state accompanying threats to oneself. Healthy stress levels motivate one toward growth. Stress overload diminishes one’s ability to cope effectively. Stress Tolerance is variable and based on current and ongoing stressors, as well as coping ability. 23-2  Mental Health Care One in three Canadians experiences mental illness at some time in their lives. Mental disorders are associated with increased use of health care resources and overall costs of care for older Canadians. Up to 30% of older adults will experience a mental illness. The most prevalent mental health problems are: Anxiety Severe cognitive impairment Mood disorders Alcohol abuse and dependence 23-3  Cultural and Ethnic Disparities Lack of knowledge and awareness of cultural differences about meaning of mental health Differences in the way concerns may present Lack of culturally competent mental health treatment Limited research Barriers to accessing services include: Cultural beliefs Lack of culturally appropriate services Lack of services in the older person’s language Lack of awareness of services Ageism 23-4  LGBTQ2 Older Adults Approximately 400,000 older adults self-identify as members of the lesbian, gay, bisexual, transgender, queer or questioning, and Two-Spirit (LGBTQ2) community. Sexual identities other than heterosexuality have not always been accepted in society, and many older adults who identify as LGBTQ2 were stigmatized or felt the need to hide their sexual orientation to prevent discrimination. Sexual orientation was thought of as a mental illness and was not protected under the Canadian Charter of Rights and Freedoms until 1996. 23-5  Indigenous Older Adults Most Indigenous older adults have experienced severe trauma in their lives. Feelings of anxiety and depression stem from residential school experiences build on previous trauma of injustice and oppression. Many Indigenous people are cared for in the community; those who move into LTC homes away from their community may experience social isolation. 23-6  Assessment and Mental Illness Includes a Mental Status Exam and Holistic Assessment: Observation of appearance Behaviour and examination of cognitive function Functional abilities Anxiety Adjustment Reactions Depression Substance abuse Suicidal risk 23-7  Anxiety Disorders Anxiety disorders are defined as unpleasant and unwarranted feelings of apprehension, which may be accompanied by physical symptoms. Anxiety is a normal human reaction and part of the fear response; it is rational, within reason. It becomes problematic when it is prolonged and exaggerated and begins to interfere with function. About 11% of older persons experience anxiety. Anxiety disorders that may occur in older people include: General Anxiety Disorder (GAD) Phobic Disorder Obsessive-Compulsive Disorder Panic Disorder Post-Traumatic Stress Disorder (PTSD) 23-8  Implications for Gerontological Nursing and Healthy Aging Assessment Anxiety in older adults is associated with more visits to primary care providers and an increase in the average length of visits Focuses on physical, social, and environmental factors, as well as past life history and recent events See Box 23-3: Suggested Questions for Identifying Anxiety in Older Adults 23-9  Interventions for Anxiety Treatment choices depend on the symptoms, specific anxiety diagnosis, comorbid medical conditions, and current medication regimen. Nonpharmacological interventions are preferred, and are often used in conjunction with medication. Cognitive behavioural therapy (CBT) Individual or group formats Designed to modify thought patterns, improve skills, and alter the environmental states that contribute to anxiety May involve relaxation training and cognitive restructuring, and education about signs and symptoms of anxiety Pharmacological interventions Antidepressants (SSRIs) Short-acting benzodiazepines (alprazolam, lorazepam ) Nonbenzodiazepine anxiolytic agents (buspirone) 23-10  Other Anxiety Disorders Obsessive Compulsive Disorder Recurrent and persistent thoughts, impulses, or images (obsessions) that are repetitive, purposeful, and intentional urges Ritualistic behaviours (compulsions) that improve comfort level, but are recognized as excessive and unreasonable Post-Traumatic Stress Disorder Development of symptoms after a traumatic event Involves experiencing, witnessing, or unexpectedly hearing about actual or threatened death or serious injury to oneself or another closely affiliated person 23-11  Psychosis and Paranoia Psychosis A syndrome or constellation of psychiatric symptoms that occur in a number of physical and mental disorders. Predominating symptoms include hallucinations and delusions. Risk factors for psychosis in older persons are social isolation, sensory deficits, physical illness, cognitive impairment, and polypharmacy. Paranoia This is sometimes induced by alcoholism or medications; hearing impairment may accentuate feelings. Fear and a lack of trust based in reality may become magnified. The dynamics of paranoia seem to be loss of control, inability to evaluate the social milieu appropriately, and the feeling of external forces controlling one’s life, which in many instances may be true. 23-12  Delusions Beliefs that guide one’s interpretation of events and help make sense of disorder May be comforting or threatening, but they form structure for understanding situations that might seem unmanageable Conceivable ideas, without foundation in fact, persisting for more than one month False fixed beliefs that are not shared by others and that guide the person’s interpretation of events Common delusions of older adults: being poisoned, children taking their assets, being held prisoner, or deceit by a spouse or lover. 23-13  Hallucinations Hallucinations are sensory perceptions of a nonexistent object and may be in relation to any of the five senses. Hallucinations arising from psychotic disorders are less common among older adults. Many hallucinations are associated with disorders such as dementia, Parkinson’s disease, physiological and sensory disorders, and medications. 23-14  Schizophrenia A severe mental disorder characterized by two or more of the following symptoms: Delusions Hallucinations Disorganized thinking Disorganized or catatonic behaviour Affective flattening Poverty of speech Apathy 23-15  Bipolar Disorder and Mania Bipolar disorder is not common in later life, but with the growing numbers of older adults, more cases will be seen. Characterized by periods of mania and depression Often levels out in late life; individuals tend to have longer periods of depression Frequent relapses may occur with aging and may be precipitated by medical problems 23-16  Depression Depression is not a normal part of aging. Depression is the most common mental health problem in later life and remains underdiagnosed and undertreated. Factors of health, gender, developmental needs, socioeconomics, environment, personality, losses, and functional decline are all significant to development of depression in later life. Causes are biological, such as neurotransmitter imbalances or dysregulation of endocrine function. Older people who are depressed report more somatic complaints, such as physical symptoms, insomnia, loss of appetite and weight loss, memory problems, or persistent pain. 23-17  Implications for Gerontological Nursing and Healthy Aging (1 of 2) Assessment A systematic and thorough evaluation using a depression screening instrument Interview History and physical Functional assessment Cognitive assessment Laboratory tests Medication review Determination of iatrogenic or medical causes Family interview 23-18  Implications for Gerontological Nursing and Healthy Aging (2 of 2) Interventions Pharmacotherapy Psychotherapy Psychosocial interventions, and electroconvulsive therapy (ECT) 23-19  Suicide In 2019, approximately 57.8 per 100,000 population of those aged 65 years old or older were known to have died by suicide. Older adults who have suicidal behaviour are more likely than younger adults to use lethal methods such as hanging, poisoning, and firearms. One of the most significant risk factors for suicide is having a depressive disorder. As many as 97% of older adults who die from suicide have a mental illness. Older adults who are depressed or suicidal often present to their primary care providers with somatic symptoms rather than with psychological symptoms. This suggests that opportunities for assessment of suicidal risk are present but may be missed. 23-20  Implications for Gerontological Nursing and Healthy Aging Assessment The most important consideration for the nurse is to establish a trusting and respectful relationship with the person. Use direct and straightforward questions: “Have you ever thought about killing yourself?” “How often have you had these thoughts?” “How would you kill yourself if you decided to do it?” Interventions Patients at high risk should be hospitalized. Patients at moderate risk may be treated as outpatients, provided they have adequate social support and no access to lethal means. Patients at low risk should have a full psychiatric evaluation and be followed up carefully. 23-21  Substance Use Disorders: Alcohol (1 of 2) The most common type of substance-use disorder is problem drinking. It can often go unrecognized, although the residual effects of alcohol abuse complicate the presentation and treatment of many chronic disorders. Gender Issues Men are four times more likely to abuse alcohol than women. Women of all ages are significantly more vulnerable to the effects of alcohol misuse. Often, alcohol abuse in women is undetected until the consequences are severe. 23-22  Substance Use Disorders: Alcohol (2 of 2) Medication Effects Alcohol interacts with at least 50% of prescription medications. Analgesics, antibiotics, antidepressants, benzodiazepines, H2 receptor blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal medications Diminishes the effects of oral hypoglycemics, anticoagulants, and anticonvulsants Physiology Older people develop higher blood alcohol levels because of age-related changes that alter absorption and distribution of alcohol. Reduced liver and kidney function slow alcohol metabolism and elimination. Risks of gastrointestinal ulceration and bleeding may be higher in older adults. 23-23  Other Substances Illicit Drugs Use of illicit drugs does not mean that the person has a substance use disorder. Problematic illicit drug use is present when it interferes with health, functioning, relationships, responsibilities, or safety. Prescription and Over-the-Counter (OTC) Medications Medication misuse is defined as use of a medication for reasons other than those for which it was prescribed. Most older adults who misuse medications do so unintentionally. 23-24  Implications for Gerontological Nursing and Healthy Aging (1 of 2) Assessment Comprehensive medical history Physical exam Cognitive assessment Functional assessment Review of medications Screening for alcohol use and depression 23-25  Implications for Gerontological Nursing and Healthy Aging (2 of 2) Alcohol Nurses should share information with older adults about safe drinking and the deleterious effects of alcohol. A caring and supportive approach that provides a safe and open atmosphere is the foundation for the therapeutic relationship. Acute alcohol withdrawal Withdrawal can become a life-threatening emergency. Detoxification should be done in an inpatient setting because of the potential medical complications and because withdrawal symptoms in older persons can be prolonged. Delirium tremens (DT) is the term used to describe alcohol withdrawal delirium. 24-29  Problem Gambling Problem gambling: 1. Interferes with work, school, or other activities 2. Harms mental or physical health 3. Hurts the person financially 4. Damages the person’s reputation 5. Causes problems with family or social relationships 24-30  Implications for Gerontological Nursing and Healthy Aging Assessment A non-judgemental approach is important. Screening for problem gambling can be integrated into the assessment of recreation and leisure activities and assessment of financial well-being. Interventions Public education and increased public awareness of problem gambling contributes to prevention, early identification, and earlier treatment of gambling. A good educational tool is Betting on Older Adults: A Problem Gambling Awareness Kit. 23-28