Chapter 31: Caring for Older Adults in Psychiatry

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Welcome back to the Deep Dive.

Today we're really digging into the essentials of psychiatric nursing care for older adults.

Yeah, getting the core knowledge, the key terms, the clinical implications.

Exactly.

Straight from the source material.

And we have to start with the demographics because they really set the stage, don't they?

They absolutely do.

It's, well, it's a huge global shift we're seeing.

The number of people aged 65 and older.

It's set to jump from about 9 % in 2019 to 16 % by 2050.

16%.

That's one in six people worldwide.

One in six.

And in the U .S.

specifically.

Well, the median age is definitely climbing, you know, driven by the baby boomers.

But here's a really stark figure.

U .S.

life expectancy actually dropped by a whole year in the first half of 2020.

A full year.

Wow.

Mostly due to the pandemic, right?

Primarily the pandemic, yes.

And hitting minority communities harder, which is crucial context.

It really is.

And that drop, it just highlights the vulnerability and underscores, I think, the core problem we're tackling today.

Which is that so many psychiatric issues in older adults just go untreated.

Symptoms get, well, they get denied or maybe written off as just getting older.

Or there's still that stigma, that shame.

Exactly.

And the key message has to be, conditions like major depression,

they are not a normal part of aging.

Absolutely not.

OK.

Let's unpack that then.

Starting with major depressive disorder, MDD.

The text makes it clear it's much more common in older adults with chronic health problems.

Right.

Which is a huge proportion.

Something like 80 % of older adults have at least one chronic condition.

And the prevalence varies quite a bit depending on where they live?

It does.

Maybe one to five percent of the community living independently.

But a jump to people getting home health care, it's up around 13 .5 percent.

That's a significant jump.

It is.

But the real clinical challenge often lies in figuring out what's really going on, differentiating.

Ah, the three D's, depression, delirium, dementia.

How do we tell them apart?

Especially say depression versus that quiet, hycoactive delirium.

They can look similar, right?

Apathy, withdrawal.

They can look very similar.

The absolute key is the onset.

How quickly did it start?

Delirium comes on fast.

Like hours or days.

It's usually tied to something physiological happening right now.

An infection, a drug reaction, a metabolic issue.

Right.

Sudden change.

Sudden change.

Depression, on the other hand, it develops more slowly.

It's a sustained change lasting at least two weeks, usually longer.

And dementia.

Dementia is that slow, gradual decline.

Insidious onset, leading to significant long -term memory problems that really mess with daily life.

So onset timing is critical for assessment.

This next point feels incredibly urgent.

Suicide risk.

The source highlights specific high -risk groups.

Yes, very high risk.

Men 65 and older and then adults 85 and older, that's regardless of gender, among the highest rates.

And it's probably even higher than the official numbers show.

Almost certainly.

It's likely under -reported because, well, older adults might use passive or indirect means.

Like what?

Like misusing alcohol or maybe stopping essential medications like their heart pills or insulin.

Or even hoarding medications is harder to track.

That idea of passive suicide, like stopping meds, that's really subtle and difficult to screen for.

It implies we need to look beyond just direct questions.

Absolutely.

A holistic view is essential.

So the risk factors we look for are things like a diagnosed psychiatric illness, stressful life events happening recently.

Like loss, bereavement.

Exactly.

And critically,

access to means do they have guns, large amounts of pills.

Okay.

And protective factors.

What helps?

Spiritual beliefs can be protective, being married often is.

And strong social connections, family support, those are vital.

And if MDD is diagnosed, what about treatment?

Well, pharmacologically,

SSRIs, selective serotonin reuptake inhibitors, they're still the first line.

Okay.

If there's also pain involved, like chronic pain or diabetic neuropathy, then SNRIs, these serotonin and norepinephrine reuptake inhibitors might be a better choice.

And for cases that don't respond well to medication.

Then electroconvulsive therapy, ECT, is mentioned as being highly effective and actually quite safe for older adults, even those who might not tolerate meds well.

So managing depression, watching for suicide risk,

huge priorities, but anxiety is another big one, isn't it?

It is, yes.

Generalized anxiety disorder is the most common type here.

And the text points out a really specific issue, fear of falling,

FOF.

Yes, FOF.

It can become so intense that people severely restrict their activity.

It starts looking a bit like agoraphobia.

They're afraid to go out, afraid to move around.

Exactly.

Which unfortunately leads to muscle weakness, worse balance.

And that actually increases their real risk of falling.

It's a tough cycle.

And this connects to a really important medication warning, especially around anxiety treatment.

A very important one.

Benzodiazepines, think Xanax, Valium, drugs like that, they should generally be avoided, if possible, in older adults.

Why is that?

Because they significantly increase the risk of falls,

fractures, confusion, even delirium.

And there's growing evidence linking long -term use, especially of the long -acting ones, to a higher risk of dementia.

So SSRIs are generally preferred for anxiety too, then?

Yes.

They're often a safer first choice, balancing the need for symptom relief against those long -term risks.

OK, let's shift gears slightly to delirium and the more chronic neurocognitive disorders.

We know delirium is rapid onset, temporary.

What's the nurse's first job when assessing possible delirium?

You absolutely have to figure out the patient's baseline functioning.

What were they like before this confusion started?

And you probably need family for that, right?

The patient might not be able to tell you accurately.

Almost always need family or caregivers.

You need to ask really specific questions.

Was she managing her own finances last week?

Could he cook for himself?

That comparison is key.

Is this new or is it their norm?

Makes sense.

And for the chronic conditions like Alzheimer's, what the text calls neurocognitive disorders, there are those specific functional deficits besides memory loss.

Can you remind us of those key terms?

Sure.

There's aphasia that's difficulty finding words or expressing thoughts, then apraxia difficulty performing learned motor actions,

like using utensils or maybe brushing teeth, even if the physical ability is there.

Agnosia is the failure to recognize familiar objects or people, not recognizing a phone or maybe even a family member.

And finally, disturbances in executive functioning.

That's the higher level stuff, planning, organizing, judgment, insight.

So it's not just memory.

It's the ability to function safely and independently in the world that really erodes that lack of insight, the impaired judgment that must make them so vulnerable.

Extremely vulnerable.

Yeah.

Now, shifting again,

let's talk about substance use.

Surprisingly, maybe alcohol use disorder is the most common substance use issue in the 65 plus group.

Really?

More than prescription drugs?

According to the source, yes, especially late onset misuse.

What triggers that late onset drinking?

Often it's major life changes.

Retirement, losing a spouse, loneliness, the social structures, the routines they had for decades, they disappear.

And maybe the signs are missed or mistaken for something else.

Exactly.

It can look like depression or even early dementia.

That's why specific screening tools are important.

The text describes the MASQG.

The Michigan alcoholism screening test geriatric version.

How does that work?

It's a straightforward tool.

24 questions, simple yes, no answers tailored to older adults.

A score of five or more yes answers suggests a likely problem with alcohol.

What are some physical signs a nurse might notice?

You might see someone who is malnourished, maybe looks unkempt, seems thin.

Confusion is common.

And chronic heavy drinking can unfortunately lead to alcohol induced dementia, hitting that executive function hard.

OK, let's move into another really complex area.

Pain management and how it intersects with polypharmacy.

Pain seems to be a huge, often hidden problem.

Why is it missed so often?

Several reasons.

Systemic barriers are big.

Some older adults just believe pain is inevitable with age or they see complaining as a sign of weakness.

And sometimes health care professionals buy into that too, assume it's just part of aging.

Sadly, yes.

Ageism plays a role.

Plus, patients might not use the word pain.

They might say discomfort or aching or soreness.

We need to listen carefully to those descriptions.

So how do we assess it better, especially if communication is difficult?

The text mentions specific tools.

Right, for verbal patients, the Juan Baker faces scale is great.

You show them the different faces from a big smile for zero pain up to a crying face for the worst pain level five.

They just point to the face that matches how they feel.

Simple and visual.

Very.

And for non -verbal patients, maybe some with advanced dementia, we use the pain dad scale.

Pain any?

Pain assessment in advanced dementia.

It looks at five things.

Their breathing,

any vocalizations like moaning, the facial expression, their body language, are they tense, fidgeting, and how easily they can be consoled.

And you score each of those?

Yes, each gets a score.

And a total score of seven to 10 indicates severe pain needing urgent attention.

So once we identify pain, we run into the challenge of treating it safely, which brings us to polypharmacy, just using multiple medications.

How risky is that?

The risk ramps up frighteningly fast, taking five to seven medications.

Your risk of an adverse drug reaction basically doubles eight or more medications.

It increases fourfold.

Wow, a fourfold increase.

Why such a jump?

It's a combination of things.

Age -related changes in how the body metabolizes drugs.

Kidneys might not clear things as fast.

Plus, memory issues can lead to accidentally taking doses incorrectly.

And there's this dangerous feedback loop.

The text warns about the prescribing cascade.

What is that exactly?

It's a really insidious problem.

It happens when a side effect from one drug is mistaken for a new medical condition.

And then that new condition gets treated with another drug.

Oh, I see.

Can you give an example?

Sure.

Maybe an antipsychotic medication causes some Parkinson's -like tremors as a side effect.

Instead of recognizing it as a side effect and adjusting the antipsychotic, a doctor might diagnose it as emerging Parkinson's disease and prescribe an anti -Parkinson drug.

Adding another drug potentially with its own side effects.

Exactly.

Or, say, a dementia drug like a cholinesterase inhibitor causes diarrhea.

Then someone prescribes an anti -cholinergic drug to treat the diarrhea.

But that drug can actually worsen confusion or cause constipation.

It's a cascade of potentially harmful prescribing.

That sounds incredibly easy to fall into if you're not vigilant.

So for pain specifically, what are the safer medication approaches?

Acetaminophen is generally the first choice for mild to moderate pain.

But you have to be really careful about the dose, especially with liver issues or a history of alcohol use.

The max dose might need to be cut by 50 % or even 75%.

OK, important safety note.

What about NSAIDs, like ibuprofen?

Big caution there.

The FDA issued a warning back in 2015 that non -aspirin NSAIDs increase the risk of heart attack and stroke.

So long -term use needs careful consideration.

And opioids.

Generally avoided for chronic non -cancer pain in older adults.

The risks falls, fractures, increased mortality,

constipation, confusion often just outweigh the potential benefits in this population.

OK, let's broaden that again to systemic issues and the nursing process itself.

We mentioned ageism earlier.

Yes, and it's crucial.

Ageism is that discrimination based on negative stereotypes about aging.

And the language we use really matters.

Terms like elderly or senile, they're considered ageist now.

Older adults is preferred.

That bias even affected research for a long time, didn't it?

It absolutely did.

Older adults used to be routinely excluded from clinical trials.

People were worried about complications, polypharmacy.

But that meant drugs weren't tested on the very people most likely to use them.

Precisely.

Thankfully, FDA guidelines changed around 2012, recommending their inclusion.

Because, well, you need the trial population to reflect the real world patient population.

Especially since how bodies handle drugs changes with age.

So when a nurse is doing an assessment, given all these complexities, what's the recommended approach?

A comprehensive geriatric assessment is key.

It looks beyond just the physical exam.

It includes mental status, functional ability, what can they actually do day to day?

Plus their economic situation, social supports, the whole picture.

And the interview itself, any tips?

Privacy and quiet are essential.

Use their preferred title, Mr.

Smith, Mrs.

Jones.

And maybe, most importantly, allow enough time.

Older adults may need more time to process questions and formulate answers.

Don't rush them.

Thinking about planning care, maybe using Maslow's hierarchy.

What are the top priorities?

Safety, safety, safety, always.

Risk for falls, risk for injury, potential for errors with medication management.

Those physiological and safety needs come first.

And once those are addressed.

Then you can move to things like nutrition.

But also the higher level needs addressing loneliness, hopelessness, maybe changes in their social roles after retirement or loss.

The source mentions some specific interventions.

Cognitive stimulation, exercise.

But it highlights reminiscence therapy.

What's that?

Reminiscence is a really nice gentle technique.

It's basically guided conversation about the past.

The nurse encourages the person to talk about pleasant memories, their first car, a favorite song, a happy family event.

How does that help?

It can really improve mood, build rapport between the nurse and patient.

And it often works well even with some memory impairment because long -term memory often stays intact longer than short -term.

It taps into those preserved strengths.

That makes sense.

So bringing this all together, what are the main takeaways for our listeners?

I think first, recognize the scale the aging population means this knowledge is essential, not optional.

Second, master that differentiation.

MDD versus delirium versus dementia focus on the onset and course.

Third, always be hyper aware of suicide risk, especially passive means.

And fourth, constantly guard against polypharmacy in that dangerous prescribing cascade.

Vigilant medication management is key.

And maybe a final thought to mull over.

How does that systemic issue, ageism potentially creep into our daily practice, that negative language, those assumptions about aging,

could they unconsciously lead us to maybe downplay someone's pain report or dismiss depressive symptoms as just old age.

It's a critical question for self -reflection.

Are we truly seeing the individual and their needs or are our own biases getting in the way of providing the best, most necessary care?

Something definitely worth considering.

Thank you for taking this essential deep dive with us today.