The Elderly and Understanding Difficult Behaviors

Chinita Manbeck, LMSW

Introduction• The elderly population in the United States is exploding. As the

number of individuals in this age bracket steadily increases, the elderly are quickly becoming frontrunners for those needing assistance and attention.

• When an individual is labeled as “elderly” or “old”, these labels reposition that person from a normal position in society to a different role. The media plays a prominent role in labeling “old” as something to be ashamed of; the majority of products advertised are to reverse signs of aging.

• Myths and distorted views about aging encourage stereotyping, which results in treating the elderly in ways that are detrimental to their self-esteem, independence, mental and physical health. In addition, the elderly may begin to believe these fabrications and integrate them in their thought process and behavior.

Introduction cont.• Older adults prefer to reside in their own home but tend

to choose assisted living facilities as an alternative in an effort to maintain their autonomy and self-respect at the same time obtaining assistance with their ADLs.

• The many challenges in social service delivery for assisted living facilities are similar to those seen in a majority of continuing care communities (retirement communities, long-term care facilities, skilled nursing facilities). There are several limitations to these communities and their surrounding environment, including the high financial burden, dependency issues, and how time consuming it can to be to care for an aging person.

Demographics • The population 65 and over will increase from 35 million in

2000 to 40 million in 2010 (a 15% increase) and then to 55 million in 2020 (a 36% increase for that decade).

• The 85+ population is projected to increase from 4.2 million in 2000 to 5.7 million in 2010 (a 36% increase) and then to 6.6 million in 2020 (a 15% increase for that decade).

• Over one in every eight, or 12.9%, of the population is an older American.

• Persons reaching age 65 have an average life expectancy of an additional 18.6 years (19.9 years for females and 17.2 years for males).

• Older women outnumber older men at 22.7 million older women to 16.8 million older men.

Demographics cont.• About 30.1% of all older persons in 2009 lived alone

(8.3 million women, 3.0 million men). The proportion living alone increases with advanced age. Among women aged 75 and over, for example, half (49%) lived alone.

• 1.6 million of the 65+ population in 2009 lived in institutional settings such as nursing homes.

• However, the percentage increases dramatically with age, 0.9% for 65-74 years to 3.5% for 75-84 years and 14.3% for 85+.

• In addition, approximately 2.4% of the elderly lived in assisted living with at least one supportive service available to their residents.

Overview of Alzheimer's Disease and Dementia• About 3.4 million people, or 13.9 percent of the population

age 71 and older, have some form of dementia. As expected, the prevalence of dementia increased dramatically with age, from five percent of those aged 71 to 79 to 37.4 percent of those age 90 and older.

• About 2.4 million of those with dementia, or 9.7 percent of the population age 71 and older, were found to have Alzheimer's disease, the most common cause of dementia.

• 75% of Long Term Care patients/residents have some form of dementia.

• Most common disease with dementia symptoms is Alzheimer's, it is the sixth leading cause of death in the U.S. (2008).

Dementia•Dementia means loss, there for it is a

decline from the previous level of functioning.

•Describes a group of symptoms and is not the name of the disease.

•Loss of abilities in memory, behavior, social skills, language, sensory perception and muscle control.

Types of Dementia•Types of dementia-•Reversible; depression, substance abuse, infections, head trauma, B 12 or thyroid deficiency

•Irreversible; Alzheimer's, Parkinson's, Vascular Dementia, Lewy Body, Frontal Lobe Damage

Alzheimer's Disease•Autopsy is the only way for a definitive

diagnosis of Alzheimer’s•95% accuracy through:•PET scan•Cognitive status exams•Neurological examination•Lab test (beta-amyloid levels)

Alzheimer’s affects a person’s ability to:• Understand our reality; live in their reality• Understand language:• Word loss, can’t find words vocabulary shrinks• Organize thoughts and ideas into words• Revert to former language• Speak• See the world as it is• Visual impairments• Hallucinations• Shadows• Hear the world as it is• Sound location• distortion

Behaviors and Symptoms• Wandering• Pacing• Confusion• Sleeping• Rummaging/hoarding• Want to go home• Want’s Mom• Socially inappropriate• Sexually inappropriate• Loss of ADL function• Delusions• Hallucination• Communication loss• Anxiety• Aggression• Sundowning

Mental Illness/Disorders•Mental illness/disorder is a term that

describes a broad range of mental and emotional conditions.

•DSM-IV defines it as a collection of symptoms, behavioral or psychological that causes an individual distress, disability, or the increased risk of suffering pain, disability, death or the loss of freedom.

Most common forms of mental illness/disorders•Depression•Bipolar Disorder (Manic-Depressive)•Anxiety Disorders•Panic Disorders•Obsessive Compulsive Disorders•Personality Disorders•Schizophrenia

Treating mental illness/disorders•Symptoms can often be controlled

effectively by:•Behavior management•Psychotherapy•Medication•Symptoms may even go into remission but

illness can continue to cause periodic episodes that require treatment.

Neurosis / Psychosis•Neurosis; grounded in reality but

thinking/behaving are dysfunctional•Depression•Bipolar Disorder•Personality Disorders•Psychosis; cannot differentiate between

what is real and imaginary (often episodic)

•Schizophrenia•Bipolar Disorder

Depression in Older Adults•Older depressed individuals often have

severe feelings of sadness and loss, but these feelings are not acknowledged or openly shown.

•Thinking that depression is an inevitable sign of aging, many people ignore or deny their symptoms.

•Highest rate of suicide is in the over 65 years of age group. One suicide every 90 minutes.

Symptoms of Depression in the Older Adult• Memory problems• Confusion• Social withdrawal• Loss of appetite• Sleeplessness• Irritability• Delusions and hallucinations• Chronic Pain and or medical complaintsUnaddressed depression in the older adult is too often assumed to be an untreatable form of dementia. Memory loss is not a normal part of aging.

Bipolar Disorder (Manic Depressive)•Mood disorder involving episodes of

serious mania and depression.•Multiple types exist with varying degrees

of mania and depression.•Usually begins in adolescence or early

adulthood and continues throughout life.

Criteria for Depressive and Manic Episode• Sad mood lasting more than two weeks• Lost of interest• Weight loss or gain• Excessive sleeping or extreme lack of sleep• Reduced psychomotor activity• Fatigue• Loss of sense of self worth• Lack of concentration• Thoughts of death• Manic Episode• Reduced need for sleep• Increased talkativeness• Easily distracted• Hyper psychomotor activity• Increased sex drive• Poor judgment• Psychotic feature• Impaired Grandiosity or exaggerated self esteem

Anxiety Disorders• A feeling of dread or apprehension sufficient enough to

interfere with daily functioning• Anxiety disorders can make a person avoid everyday,

routine functions altogether in an effort to curb the stressful feelings they cause

• Signs any symptoms include inability to concentrate, sleep disturbances, panic attacks, irritability, excessive worry

• Physical symptoms; dry mouth, heart palpitations, fatigue, muscle tension

• It is common for one anxiety disorder to coexist with another disorder or several others (e.g. anxiety and depression).

Panic Disorder-Phobias• An anxiety disorder that exhibits instance of extreme fear

or discomfort• Starts abruptly and builds to a rapid peak, usually within

ten minutes• Usually accompanied by a sense of looming danger and

the strong desire to escape• Brought on by specific phobias or triggers, or can occur

“out of the blue”• Signs and symptoms include heart palpitations, sweating,

trembling, shortness of breath, the sensation of choking, chest pain, nausea, dizziness, disorientation, fear of losing control or dying, numbness, chills and hot flushes

Obsessive Compulsive/HoardingThe excessive collection and retention of things or animals. An excessive attachment to items collected and the inability to part with them. Stems from the inability to make decisions or fear of loss.Elderly with dementia and Schizophrenia 700,000 to 1.4 million of them are hoarders.

HoardingOlder adults hoard for the following reasons:• Obtaining love not found from people• Fear others will obtain their personal information• Physical limitations and fragility• Self neglect• Stressful life event• Delusional• Excessive attachment to possessions• Inability to discard items• Organizational difficulty• Perfectionism• Difficulty permitting others to touch or move accumulated items• Procrastination• Trouble making decisions• Difficulty managing daily tasks• Limited or poor socialization skills

Personality Disorders•Great difficulty interacting with other

people•Tendency to be inflexible, rigid, and

unable to respond to changes and life demands

•Often feel their behavior patterns are “normal or “right”

•Tend to have a narrow view of the world and find it difficult to participate in social activities

Continued…• There are many formally identified personality

disorders, each with their own set of behavior and symptoms. Many of these fall into three different categories;

• Cluster A: Odd or eccentric behavior, e.g. Schizoid Personality Disorder, Paranoid Personality Disorder

• Cluster B:Dramatic, emotional or erratic behavior; e.g. Anti-social Personality Disorder, Borderline Personality Disorder, Multiple Personality Disorder

• Cluster C:Anxious fearful behavior, e.g. Dependent Personality Disorder, Avoidant Personality Disorder

Schizophrenia• An organic brain disease linked to changes in the

brain chemistry and structure• Impairs a person’s ability to think clearly, manage

his emotions, make decisions and relate to others• For initial diagnosis must have two of the

following: Delusions, hallucinations, disorganized behavior, disorganized speech and negative symptoms (flat or blunted affect)

• 75% develop it between ages of 16 and 25• Affects approximately 2% of the population in the

U.S.

Alcohol and Substance Abuse • The elderly rarely use alcohol or drugs to “get high”; drug

or alcohol use that begins after age 60 appears fundamentally different.

• The elderly turn to alcohol and drugs to alleviate the physical and psychological pain from the onslaught of medical and psychiatric illness, the loss of loved ones or social isolation.

• Psychoactive drugs are all addicting and can impair cognitive functioning, cause depression, increase the risk of falling and interact dangerously with other medications.

• Moreover, drug and alcohol abuse in older patients occurs alongside other medical and psychiatric illnesses.

Alcohol and Substance Abuse cont.• Numerous surveys document problematic drinking

among the elderly. For example, a 2011 National Survey on Drug Use and Health found that 8.3 percent of adults 65 and older reported binge drinking, defined as having four or five drinks on one occasion in the past month.

• Although alcohol is clearly the most commonly abused drug in the elderly, nonmedical use of prescription drugs is a rapidly growing threat. Some studies estimate that up to 10 percent of the elderly misuse prescription drugs, most often Klonopin, Ambien and opiate painkillers like Oxycodone.

Alcohol and Substance Abuse cont.•Of the current population, 83% of older adults,

take prescription drugs. Older adult women take an average of five prescription drugs at a time, for longer periods of time, than men. And studies show that half of those drugs are potentially addictive substances, making older females more vulnerable to potential abuse. Women outnumber men when it comes to nonmedical use of prescription medication: 44% of women vs. 23% of men.

Alcohol and Substance Abuse cont.• Various studies have shown that within the elderly population:• 19.1 % are at risk drinkers; 8.9% are heavy drinkers; 54.2%

are moderate drinkers• 10.2% reported cocaine use• 8.3% reported heroin use• 21.1% prescription drug misuse/abuse• 16% smoked tobaccoScreening for drug abuse in the elderly can be complicated. Symptoms can be masked by normal or perceived signs of aging, the elderly may deny symptoms of abuse, and may be unaware of their misuse. The elderly do not fit the typical drug abuser profile or stereotype and therefore awareness and services for this population are lacking.

TreatmentTreatment may include psychopharmacology, cognitive behavior therapy, reminiscence therapy, behavior therapy, education, and increased social support.Cognitive therapy is an effective, directive, time-limited approach to helping people change their irrational thoughts, assumptions, and beliefs. Cognitive therapy and medications have been more effective than either treatment alone. Cognitive theory suggests that disorders arise from a negative view of the world and from automatic and negative thinking patterns (e.g., the future is bleak, the world is bleak, and the self is worthless).

Treatment Cont.•Extensive research shows that specific

habitual patterns of behavior and thinking are associated with a number of mental disorders. The purpose of CBT is to help the patient reduce or eliminate the behavior and thinking patterns that are contributing to his/her suffering and to replace dysfunctional patterns of behavior and thought with patterns that promote health and well-being.

Treatment Cont.Reminiscence therapy is the process of recalling personal experiences from an individual’s past. The theory behind RT is that an individual’s function is improved by decreasing demands on impaired cognitive abilities; it is a way to affirm who they are, what they’ve accomplished in their lives, and a chance to relive happy times. For those who suffer with dementia, depression or anxiety it is a way to talk easily about things they do remember.

Treatment Cont.Behavioral therapy is a treatment that helps change potentially self-destructing behaviors, also called behavioral modification. This type of therapy is utilized to replace bad habits with good ones and helps individuals cope with difficult situations; most often used to treat anxiety disorders. Most behaviorally oriented therapists believe that the current environment is most important in affecting the person’s present behavior, while early life experiences and emotional/psychological conflicts are less important.Behavior therapy is generally intended to improve the individual’s self-control by expanding coping skills, abilities, and independence.

Discussion• As the elderly population in the United States grows, the

number of individuals with behaviors will certainly increase tremendously.

• Unfortunately, beliefs typically attributed to the elderly about their mental health tend to be myths: elderly are assumed to experience greater psychological problems; older adults are thought to be plagued by sadness and loneliness; tormented by fears of death and dying; families abandon their older relatives and that the elderly almost always suffer from dementia.

• With the growing geriatric population, greater attention should be dedicated to the lives of seniors and toward ensuring their physical, mental and emotional health as they move toward later life; the elderly should not only be adding years to their lives, but also life to their years.

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