Older Adults Mental Health Approaches and Treatment Methods

Mental Health Treatment Approaches for Older Adults

Overview of mental health issues in the elderly

Old age is a natural occurrence for every human being, a stage in growth accompanied by several changes, which can be negative and identified as problems. Some of these problems are a rise in morbidity, mortality, hospitalization, and functional status loss. A large number of evidence associates these problems with common mental disorders to which the elderly are prone. A combination of depression and anxiety is a very common occurrence in the elderly, being so prevalent, one-half of elderly patients report significant anxiety or depressive symptoms (Parkar, 2015). The changing nature of current society has redefined the social role of the elderly within the family and community, eliminating the traditional life-sustaining and fostering influences the elderly contributed. As a result of these, the elderly are socially isolated. Many are committed to a nursing home or an institution where the only available social links are other equally alienated older adults.

The contributions of the elderly to families and society, while limited, are not irrelevant. Older adults aged 60 and above still make valuable contributions as family members, volunteers in the community, and active part of a society’s workforce. However, the effectiveness of the elderly’s contribution can be limited by the individual’s mental health condition. While most elderly have good mental health, there is a high risk of an aged individual developing mental disorders. As age advances, the risk of suffering a mental disorder rises. Over 20% of adults the age of 60 and over suffer from a mental or neurological disorder (excluding headache disorders), and mental and neurological disorders account for 6.6% of all disabilities (disability-adjusted life years – DALYs) in persons aged 60 and over (WHO, 2017). The three most common mental and neurological disorders in the world’s older population are depression, dementia, and anxiety, conditions that affect 7%, 5%, and 3.8% of the world’s older population.

Mental health conditions are often unrecognized by healthcare professionals and the elderly themselves who suffer these conditions. In the eventuality of accurate identification, many sufferers of such conditions are reluctant to seek professional help due to the stigma linked with the conditions. This paper focuses on dementia as a mental health issue that affects the elderly.

Dementia

Dementia is considered to be a syndrome (a group of symptoms), either chronic or progressive, which interfere with cognitive function (the ability to process thought) and exhibit mental ability deterioration beyond what might be expected from normal aging. Dementia affects several mental faculties, including thinking, memory, orientation, calculation, learning capacity, comprehension, language, and judgment, but consciousness is not affected. Symptoms such as deterioration in emotional control. Social behavior and motivation commonly precede cognitive impairment manifestation but occasionally occur in accompaniment (WHO, 2020). The resulting lack of personal ability caused by dementia is recognized as the leading cause of dependency among the elderly worldwide. The poor understanding of this mental health issue has led to the association of stigma with dementia, a social factor that can interfere with diagnosis and care. The situation created by this condition can be overwhelming for everyone involved, including the patient, the carer of the patient, and the family. The resultant impact of dementia on the patient, the family, and society can be physical, psychological, social, and economic.

Dementia, although not a normal aspect of aging, is most prevalent in older adults. An estimated number of 50 million people worldwide live with dementia, with 60% of that population distributed in low- and middle-income countries. The total number of dementia patients worldwide is projected to rise to 82 million in 2030 and 152 million in 2050 (WHO, 2017). In addition to the high economic cost of medical, social, and informal care required for dementia patients, the families and carers for the patients are also subject to great physical and emotional stress. As such, support from the health, social, financial, and legal systems is required for the dementia patient and the carers, and the family.

Possible causes

The following factors are recognized as the most common causes of dementia (Livingston et al., 2020):

· Degenerative neurological diseases: Like Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, and some variants of multiple sclerosis. These neurological diseases are characterized by an increase in severity as time advances;

· Vascular disorders which impair the circulation of blood to the brain;

· Brain injuries caused by trauma during a car accident, fall, concussion, etc.;

· Certain infections of the central nervous system such as meningitis, HIV, Creutzfeldt-Jakob disease;

· Persistent use of drugs or alcohol;

· Certain types of hydrocephalus (a build-up of fluid in the brain).

The risk of developing dementia is also influenced by physical and lifestyle factors such as:

· Age;

· The history of dementia in the family;

· The existence of underlying illnesses such as diabetes, Down syndrome, heart disease, and sleep apnea (Shi et al., 2018);

· Poor diet and a lack of exercise;

· Cognitive inactivity, social isolation, and depression.

Characteristics or symptoms

There is a variance in the manifestation of dementia in each person, based on factors such as the illness’s impact and the individual’s personality before being affected (WHO, 2020). However, the progression of dementia is similar enough for three distinct stages to be identified.

Early-stage: This stage can be difficult to identify as the onset of the illness is gradual. During this time, identifiable symptoms are forgetfulness, a poor consciousness of time, and becoming lost in familiar places.

Middle stage: As dementia advances into this stage, the symptoms become more evident and more serious. The affected individual becomes more forgetful of recent events and people’s names, becomes lost at home, has greater difficulty communicating, needs help with personal care, and experiences behavioral changes (such as wandering and repeated questioning).

Late-stage: At the late stage, the affected individual will become near totally independent and inactive. Severe memory disturbances will occur, and physical symptoms will become very obvious. At this stage, the affected individual will become unaware of the time and place, have difficulty recognizing relatives and friends, become increasingly dependent, have difficulty walking, and exhibit behavioral changes, including aggression.

Treatment and prevention (if relevant), and a description of screening, assessing, and diagnosing

Assessment

The diagnosis of dementia requires a thorough clinical assessment which will cover medical history, including a cognitive and mental state examination, physical examination, and other relevant investigations (Panegyres, Berry & Burchell, 2016). The patient’s assessment is to be completed with a knowledgeable informant, as the information produced by an unreliable patient is not admissible. Informant-based assessments provide greater sensitivity than the MMSE (mini-mental state examination) in detecting dementia and changes in biomarker profiles of Alzheimer’s Disease, particularly in the early symptomatic stages.

Screening

i. Cognitive Testing

Various tests are available to screen for cognitive decline, with the mini-mental state examination (MMSE) being the most widely used (Panegyres et al., 2016). The MMSE takes about 15 minutes to complete, and the result of the test is rated on a scale of 0 to 30. The value obtained indicates the current level of cognitive impairment.

The Montreal Cognitive Assessment (MoCA) is a screening tool used for a similar function of detecting cognitive impairment, but only in mild cases. The test requires 10 minutes to complete.

This paper identifies two other cognitive tests which are as clinically and psychometrically robust as the MMSE, The General Practitioner Assessment of Cognition (GPCOG) screen, and Mini-Cog testing.

ii. Functional Status

The current ability to complete day-to-day activities with no observable impairment has to be determined to assess for dementia. The testing tool used for this observation is The Functional Activities Questionnaire (FAQ). The FAQ is a brief standardized assessment used to obtain objective evidence from an informant, such as a family member or spouse, on the patient’s competence in completing daily activities.

iii. Review of Medications

Certain medications can interfere with the assessment of dementia in a patient. With the common occurrence of polypharmacy in the elderly, there is a high risk of this interference. Therefore, a full review of all medication, prescribed or over-the-counter, which the patient uses must be completed. From the information contained in the review, drug classes that the patient uses can result in cognitive impairment. Some of the common drug classes that impair the cognitive function are opioids, tricyclic antidepressants, anticholinergics, muscle relaxants, antihistamines, and antiepileptics benzodiazepines, and non-benzodiazepine hypnotics (Panegyres et al., 2016). Information on a history of alcohol consumption, smoking, and illicit drug usage is also very essential.

iv. Neurological Evaluation

The neurological status of a patient is required to diagnose dementia. The neurological status is assessed by completing a neurological evaluation on the patient. This evaluation should include vision, speech, hearing, and movement assessments. The existence of an aberration in any of the mentioned functionalities can indicate a health condition that can cause dementia. A speech impediment might indicate Parkinsonism’s presence, while poor motor skills can indicate FTD, Parkinsonism, normal pressure hydrocephalus, or stroke. Any history of head injury or neurological disorder must be acknowledged, like traumatic brain injury and epilepsy are risk factors for the onset of early cognitive decline (Vossel et al., 2017). The patient’s sleep patterns can also indicate a cognitive decline, especially if the patient suffers from sleep apnea or restless legs syndrome.

v. Social History

An examination of a person’s social history can be used to detect a change in cognitive function level. Different factors influence social history, including education, hobbies, occupation, home life, and supports.

vi. Additional Testing

Structural imaging technology, preferably MRI, can identify potentially reversible causes of dementia such as stroke, subdural hematomas, hydrocephalus, and intra-axial and extra-axial tumors (Montgomery, 2020). In compliance with UK, European, and American medical guidelines, structural imaging should be used during the initial investigation of dementia patients. The recommended options for achieving this function are non-contrast CT and MRI, with MRI being the preferred option.

Subtypes of neurodegenerative dementia can be differentiated by assessing neuronal function. Positron emission tomography (PET) using 18-F-fluorodeoxyglucose (FDG) and SPECT using 99mTc-hexamethyl propylene amine oxime (99mTc-HMPAO) are both techniques available for conducting such an examination.

Prevention

Studies on dementia show that developing the condition can be lowered by adopting a healthy lifestyle. Practices such as getting regular exercise, controlling body weight, adopting a healthy diet, and maintaining a healthy level of blood pressure, cholesterol, and blood sugar levels are recommended; while practices such as smoking, consuming large amounts of alcohol, and using illicit drugs are heavily advised against (WHO, 2020).

Treatment

Currently, dementia has no cure, and there are no treatments that can slow the illness’s progressive action. Research is still ongoing to develop a cure for dementia, with several new treatments still in various stages of clinical trials (WHO, 2020). While no definitive cure for this illness exists yet, the quality of life of dementia patients can still be improved through adequate care. The primary goals for dementia care are:

· To obtain an early diagnosis which will allow for early and optimal management;

· Optimizing cognition, activity, and well-being in the early stage;

· Maintaining physical health by treating illnesses that may arise;

· Identifying and treating challenging behavioral and psychological symptoms;

· Providing support for carers.

Ethical Considerations Related to Dementia

There are various ethical decisions persons who work in dementia care settings have to make every day. Caregivers have to attend to multiple patients, each with a specific set of needs, while safeguarding each interest. The caregiver must consider patient confidentiality, the potential for abuse of each patient, and the effects of a patient’s medication. The caregiver’s position can become more difficult if the patient is no longer able to express his/herself. The caregiver will be required to decide on the patient’s behalf and strive to decide on what is best for the patient or choose to do what the patient would have done if able.

Ethical Approaches to Care

The nature of healthcare professionals’ duty occasionally requires such individuals to make ethical decisions that can affect others’ lives. To limit potential errors due to bias and safeguard others’ lives, healthcare professionals must incorporate ethical principles into daily care. This is especially relevant in the ethically difficult area of dementia professional care. In biomedical ethics, several ethical principles are recognized as fundamental. These principles are:

· Autonomy and well-being;

· Beneficence;

· Justice;

· and Veracity (Truthfulness).

Autonomy and Well-being

The general definition of autonomy refers to an individual’s ability to make rational decisions by his/herself. Autonomy for a dementia patient bears some difference from the general definition. The ability to foster important relationships, maintain a sense of self, and possess a way to express values is identified as autonomy for a dementia patient. Well-being encompasses a person’s daily experiences of contentment and pleasure and the mental condition of the person, indicated by the level of cognitive functioning (Johnson & Karlawish, 2015; Hughes & Common, 2015).

Beneficence (Kindness)

Beneficence, in its simplest definition, refers to kindness. In a professional healthcare setting, beneficence means attempting to put the patient’s interests foremost at all times. This is most important in decision-making as the healthcare professional might have to decide on behalf of the patient. Inputting the patient’s interest foremost, the professional has to decide which will be the same regardless of who is making the decision. Beneficence is linked with the concept of “no harm.” The healthcare provider’s actions are deemed “right” if the action causes no harm and is in the patient’s interest.

Justice: Equity and Fairness

The vulnerability of persons with dementia poses a risk of exploitation. The particular topic of concern in this regard is the allocation of resources to support dementia care. The caregiver should ensure a fair distribution of the resources available to sustain the person with dementia throughout the period for which care should be given and allow the patient to maintain as much independence as possible (Hughes & Common, 2015).

Veracity (Truthfulness)

Every interaction with a dementia patient by the caregiver should be backed by ethical reasoning based on concern for the patient’s well-being. This can lead to the uprising of internal conflict within the caregiver as there exists a desire to maintain trust while reducing the patient’s distress. The caregiver’s consideration for the patient’s comfort must be balanced with the moral importance of telling the truth and the practical concerns of getting through the day (Hughes & Common, 2015).

In providing healthcare for a dementia patient, ethical concerns which arise during this effort include (Hughes & Common, 2015; Johnson & Karlawish, 2015):

· Deciding on the best time to communicate a diagnosis and how to do it;

· The best proportion of safety to independence which the patient requires;

· Needing to represent the patient’s best interests at all time, especially when making decisions on behalf of the patient;

· Balancing the needs of the patient with the needs of others such as the caregiver;

· Addressing discrimination against persons with dementia;

· Managing the resources allocated to support the dementia patient;

· Choosing the amount of time and resources to be dedicated to dementia research.

Intervention Strategy

Cognitive stimulation is an intervention strategy for persons with dementia that produce mental excitement in thinking, concentration, and memory. The stimulation occurs through a range of enjoyable activities performed in a social environment, such as in a small group. This intervention strategy aims to improve cognitive and social functioning and be administered by trained caregivers on a one-to-one basis (Thomason, 2012). The specific activities of a cognitive stimulation program can vary between programs. However, the programs still serve a similar purpose of enhancing memory, attention, and overall cognitive function in persons with mild to moderate dementia. The activities included in a cognitive stimulation program are mental training strategies that focus on memory training, general problem solving, multisensory stimulation, mnemonic devices, social activities, word games, puzzles, and the use of external memory aids such as notebooks and calendars. This intervention strategy is recommended by The National Institute for Health and Clinical Excellence (2006) for persons with mild to moderate dementia.

Loewenstein and colleagues (2004) conducted a study on two cognitive stimulation programs to compare the effectiveness of both. The program was a cognitive rehabilitation program that employed spaced-retrieval techniques, procedural memory training, a memory notebook, cueing, and other activities to create focused cognitive training. The second program employed general mental stimulation through the use of conventional and computer-based games. Forty-four persons with mild dementia participated in this study, with each individual randomly assigned to participate in one of the two cognitive stimulation programs. Both programs produced significant results in each of the participants, improving mood and memory, but the individuals assigned to the focused cognitive training program recorded the greatest improvement. A Cochrane review on the impact of cognitive stimulation interventions on people with dementia evaluated an intervention strategy’s effectiveness, including any negative effects such a program might cause (Woods et al., 2012). 718 people with dementia were included in the review; the participants were limited to patients with mild to moderate dementia occurring as either Alzheimer’s or vascular dementia. The participants were included in 15 randomized controlled tests. The review results showed that the participants who received cognitive stimulation interventions attained higher scores in cognitive function tests. The improvement registered in these patients were still evident 1-3 months after the intervention programs. Reports from participants and carers of participants in a smaller number of trials claimed the appearance of several positive effects on social interaction, well-being, and communication.

Psychosocial Issues of Dementia

Shattered Social Roles

Dementia patients are often unaware of physical or intellectual limitations they may possess and require constant supervision to prevent self-inflicted or other injury forms. At later stages of dementia, the social role of a dementia patient in a family changes. The patient may lose autonomy when a now vacant role is taken up by a spouse or child (Perel, 1998). The changes may result in the patient feeling frustration and anger, negative emotions that may be directed at the family members. The unpredictable progression of dementia contributes to family role ambiguity. The change in the patient’s personality may reduce family interactions as family members, especially those living outside the home, withdraw from the individual.

Families may choose to commit a dementia patient to a care institution when their care requirements exceed what can be provided. While this measure might be perceived as having relieved the caregivers’ physical and emotional burden, studies show that this is not always so (Perel, 1998). Families often experience feelings of guilt and anxiety after committing a dementia patient to an institution. Commuting to the institution may place time commitments upon the family members, and other factors such as distance and cultural objections may further isolate friends and family from the patient.

Depression and Dementia

The severity to which geriatric patients evaluate any depressive symptom they possess is influenced by dementia. In patients without dementia, self-evaluations on depressive symptoms and well-being completed by the patients correlate well with the assessments given by their caregivers. But patients with advancing dementia often underreport depressive symptoms (Perel, 1998). This makes it essential to develop an accurate, objective method of assessing depressive symptoms in patients with dementia.

30% of patients with Alzheimer’s Disease (AD) suffer both dementia and depression. To reduce the patient’s mental suffering and improve the quality of life, treating depression is important. A behavioral approach is a viable way of treating depression in dementia patients as the fear of disease progression subsides, self-care is improved, and feelings of hope increase. Depression in dementia leads to a gradual loss of enjoyment of activities, including activities previously perceived as enjoyable. At the onset of AD, a patient often gives up responsibilities and privileges such as driving, caring for grandchildren, and financial management. Patients who work or volunteer may no longer be able to continue such duties due to AD. This can induce feelings of loss in the patient; in responsibility, control, and status, the patient’s values might have previously defined the self (Perel, 1998). As such, feelings of uselessness and loss of self are common in AD patients. There is still little understanding of how AD patients adjust to changes experienced in functional and cognitive status. This lack of data is caused by the difficulty of assessing AD patients early in the onset of illness. A diagnosis does not often occur until the illness symptoms have progressed.