CH-30 Psychosocial Needs of the Older Adult – Varcaroliss Canadian Psychiatric Mental Health Nursing : Chapter Notes

Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 30: Psychosocial Needs of the Older Adult Instructor’s Manual Thoughts About Teaching the Topic When time is limited, the instructor may choose to assign this chapter concurrently with Chapter 18, Cognitive Disorders. The material in Chapter 18 on dementia and delirium correlates well with material in this chapter, especially relating to disorders for which older adults are at risk. Chapter Outline Teaching Strategies Mental Health Issues Related to Aging Late-Life Mental Illness Older adults who develop late-life mental illness are less likely than young adults to be accurately diagnosed and receive mental health treatment. Issues such as depression, memory loss, and prolonged grieving are not a normal part of aging and should be diagnosed and treated. Depression Depression is often confused with dementia and may go unrecognized. Depression is treatable. Symptoms of depression in older adults include change in sleep patterns and insomnia, change in eating pattern (loss of appetite), weight loss, excessive fatigue, increased concern with bodily functions, alterations in mood, expressions of apprehension and anxiety with reason, low selfesteem, and feelings of insignificance or pessimism. Depression can be caused by drugs or metabolic or endocrine diseases. Depression and Suicide Risk Research has shown that older adults who commit suicide suffer from the most treatable kind of depression but do not receive needed mental health services. In 2007, within the demographic group of older adults, the highest rate of suicide was among those Key Terms and Concepts adult support program ageism caregiver burden Objectives Discuss facts and myths about aging. Describe mental health disorders that may occur in older adults. Analyze how ageism may affect attitudes and willingness to care for older adults. Explain the importance of a comprehensive geriatric assessment. Describe the role of the nurse in different settings of care. Discuss the importance of pain assessment, and identify three tools used to assess pain in older adults. Canadians between the ages of 80 and 84 years: 11.6 per 100 000, with the rate for men 23:100 000. Approximately 70% of people who commit suicide suffer with depression. The risk for suicide is even higher if the depression is accompanied by psychosis. Early identification of and treatment for depression, therefore, are key measures for suicide prevention. Even though the suicide rate among older adults is high, suicide in this group is probably underreported. Anxiety Disorders Anxiety is twice as prevalent as dementia and four to eight times as common as major depressive disorders. The most common sources of anxiety are phobias and generalized anxiety disorder (Cremens, 2008). Substance Abuse People of any age can abuse any type of substance. Regardless of age, substance abuse has social, psychological, and physical consequences. Almost 80% of Canadians consume alcohol at least once a year (Health Canada, 2011). Although heavy drinking tends to decline with age, it continues to be a serious problem that can create particular problems for older adults. The risk factors for heavy drinking in older adults are being male and single, having less than a high-school education, having a low income, and smoking (Karlamangla, Zhou, Reuben, et al., 2006). Identifying alcohol and substance abuse is often difficult because personality and behavioural changes frequently go unrecognized in older adults. The CAGE-AID screening tool (Wagenaar, Mickus, & Wilson, 2001) (Box 30-3) and the MAST-G (Box 30-4) are instruments commonly used to assess high-risk drinking in older adults. Trauma Older adults are also susceptible to the effects of psychological trauma. Chapter 27 discusses interpersonal violence in more detail. Refer to Chapter 28 for more information regarding the consequences of sexual assault. Pain Pain is common in older adults and affects their well-being and quality of life. Up to 85% of the older population is thought to have problems such as arthritis and diabetic neuropathy, which predispose them to pain. Pain decreases ability to perform ADLs, leads to delayed healing and decreased mobility, and interferes with sleep and appetite. It may cause psychological distress, including depression, low self-esteem, social isolation, and feelings of hopelessness. Nurses should perform a full pain assessment (i.e., of pain pattern, duration, location, character, exacerbating and relieving factors, and the probable cause of the pain). Assessment Tools A number of pain assessment tools exist. The visual analogue scales, the Wong-Baker FACES Pain Rating Scale, and the present pain intensity rating scale have been found to be useful with older adults. Barriers to Accurate Pain Assessment Older adults are often reluctant to label pain as pain, calling it instead, “discomfort,” “hurting,” or “aching.” They may rank it as less important than other health problems. They may not wish to incur the cost of investigating the pain, or they may be resigned to accepting serious disease as a natural part of aging. Sensory impairment, memory impairment, and depression are also barriers to assessment. Pain Management Pharmacological pain management includes use of prescription and nonprescription medications. Nonpharmacological management includes a range of physical interventions and modalities such as exercise, positioning, acupuncture, heat or cold, massage, and transcutaneous electrical nerve stimulation (TENS). Cognitive strategies may emphasize relaxation, distraction, biofeedback, and hypnosis. Alternative medical approaches include homeopathy, naturopathy, and spiritual healing. Health Care Concerns of Older Adults Caregiver Burden Dwindling health care benefits, shorter lengths of hospital stays, limited options for care at home, and complicated procedures to access care have increased the need for adult children to advocate for and provide care to aging parents. Access to Care The disparity of mental health services in Canada has developed into a fragmented system of care so complicated that some patients become resigned to go without care. It is vital for nurses as citizens to use their knowledge, experiences, voices, and votes to advocate for equal health care for all. Ageism Ageism is a bias against older people because of their age. It is reflected in dislike of the old by the young and by the critical attitude of older adults toward themselves. Ageism results in problems such as difficulty obtaining financial and political support for programs for older adults; health care personnel failing to share medical information, recommendations, and opportunities with older adults; and failing to give mental health care to older adults. Health care workers’ attitudes are often negative and based on stereotypes. To overcome misconceptions, the author suggests that educational programs provide students with information about the aging process, discussion of attitudes relating to care of older adults, sensitization of participants to their patients’ needs, and exploration of the dynamics of nurse and staff–patient interactions. Ageism and Public Policy The needs of older adults are often addressed only after those of younger, albeit smaller, population groups. Nursing Care of Older Adults Assessment Strategies Figure 30-4 provides an example of a comprehensive geriatric assessment tool. A relevant rating tool, the Geriatric Depression Scale is displayed in the text (Box 30-7). Also, Box 30-8 provides helpful interview techniques to use with older adults. Intervention Strategies Learners are reminded that older adults who manifest mental problems are treatable and responsive. Techniques that work well with these patients are listening, crisis intervention, using empathetic understanding, encouraging ventilation of feelings, reestablishing emotional equilibrium when anxiety is moderate or higher, and explaining alternative solutions. Psychosocial Interventions Counselling assists the patient to talk about present problems in individual or group therapy. Remotivation therapy (Box 30-9) and reminiscence therapy are also appropriate interventions. Pharmacological Interventions Nurses play a vital role in monitoring, reporting, and managing medication adverse effects such as acute dystonia, akathisia, pseudoparkinsonism, neuroleptic malignant syndrome (NMS), serotonin syndrome, and anticholinergic effects. Physical assessment of response to medication is also important and includes monitoring vital signs, pain, lab work, elimination (bowel and bladder), changes in gait, prevention of falls, and neurological checks when appropriate. Health Teaching and Health Promotion The nurse provides health teaching to both patient and caregiver on a variety of issues, including the nature of the patient’s illness, symptom management, maintenance of safety, self-care strategies, management of medications (Box 30-10), coping skills, steps necessary for recovery, and resources that will support recovery. When information is printed, providing a large print version is often helpful. Promotion of SelfCare Activities A goal for nurses is to encourage the patient to regain independence in the realm of personal care. Milieu Management Major tasks for the nurse are to assist the patient in adjusting to the environment, keep the patient safe, minimize the effects of hospitalization on functional capacity, provide reality orientation, and engage in therapeutic communication. Care Settings Skilled Nursing Facilities The use of these facilities to treat older adults with severe mental illness is controversial, and opponents fear that “nursing homes” will become the mental institution of the 21st century, providing little more than custodial care. Residential Care Settings The mental health system has become more focused on providing this type of community setting as opposed to institutional settings. Partial Hospitalization and Day Treatment These are recommended for ambulatory patients not in need of 24hour care. Day Treatment Programs Multipurpose centres for older adults provide a broad range of services, including (1) health promotion and wellness programs; (2) health screening; (3) social, educational, and recreational activities; (4) meals; and (5) information and referral services. For those in need of nursing care and custodial care services, an adult support program is an appropriate choice. There are three types of adult support programs: (1) social care, (2) adult health or medical treatment programs, and (3) maintenance care. In each type, older adults are cared for during the day and stay in a home environment at night. The boundaries of these programs blend and overlap. All three models are meant to provide a safe, supportive, and nonthreatening environment and fulfill a vital function for older adults and their families. Behavioural Health Home Care This program helps the patient remain independent in his or her own home, with local home care services such as housekeeping, meal preparation, and assistance with ADLs. Community-Based Programs The hazards of institutionalization include increased mortality due to higher risk for nosocomial infections, injuries associated with disorientation to a new setting, learned helplessness, loss of interest in self-care activities, and decreased opportunities for socialization. Community-based programs provide an alternative whose purpose is to promote older adults’ independent functioning. A multipurpose senior centre provides a broad range of services: (1) health promotion and wellness programs; (2) health screening; (3) social, educational, and recreational activities; (4) meals; (5) information and referral services. Day care provides an alternative for seniors who are physically frail or cognitively impaired. Three types of day care programs exist: (1) Social day care affords patients recreation and social interaction. Nursing and rehabilitative care are usually not provided. (2) The adult day health or medical treatment model provides medical and psychiatric nursing rehabilitation for high-risk older adult patients and psychosocial interventions with the frail older adults. It requires physician referral. The goal is to prevent or slow mental, physical, or social deterioration and to maximize potential. (3) The maintenance day care model assists patients at high risk for institutionalization. Care is planned by an interdisciplinary team led by a psychiatrist. Patients include frail people with dementia and those with severe and persistent psychiatric disorders. The goal is to maintain functional abilities as long as possible. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 31: Living With Recurrent and Persistent Mental Illness Instructor’s Manual Thoughts About Teaching the Topic Students who have been assigned to units primarily caring for acutely mentally ill patients may not have experienced an opportunity to interact with and assess a severely and persistently mentally ill individual. If possible, instructors may arrange a guest presentation from a speaker’s bureau or community agency that supports education by families and patients living with recurrent and persistent mental illness who are well and living with mental illness in the community. Additionally, a 1-day observation at one of the following types of facilities specializing in caring for severely and persistently mentally ill or homeless people would be helpful: a day care centre, a medication clinic, a mobile clinic, an outreach clinic, or a temporary shelter for homeless people with mental illness or addictions. It may be possible to arrange for a student to accompany a community mental health nurse for a day as an adjunct to an acute psychiatric nursing practice experience. In many small and large cities in Canada, there are outpatient day programs and homeless shelters to deal with the needs of homeless or chronically mentally ill people. Chapter Outline Teaching Strategies Serious Mental Illness: Recurrent and Persistent The terms serious mental illness and biologically-based mental illness refer to a small but significant group of mental illnesses. In Canada, there is no uniform definition of serious mental illness (SMI) or serious and persistent mental illness (SPMI), but many Key Terms and Concepts community treatment orders (CTOs) institutionalized psychoeducation rehabilitation social skills training stigma supported-employment model supportive psychotherapy vocational rehabilitation Objectives Discuss the effects of serious mental illness on daily functioning, interpersonal relationships, and quality of life. Describe three common problems associated with serious mental illness. Discuss five evidence-informed practices for the care of the person with serious mental illness. Explain the role of the nurse in the care of the person with serious mental illness. Develop a nursing care plan for a person with serious mental illness. Discuss the causes of treatment nonadherence, and plan interventions to support treatment adherence. Canadian researchers and clinicians use serious mental illness to refer to schizophrenia, mood disorders, and other psychotic disorders. SMIs are chronic or recurrent. Some patients experience remissions interrupted by exacerbations of varying lengths; the remissions may be essentially symptom-free but in most cases involve some degree of residual symptoms. Other patients experience illness as a chronic and sometimes deteriorating experience, during which symptoms wax and wane but never remit. People with SMI are at risk for multiple physical, emotional, and social problems: they are more likely to be victims of crime, be medically ill, have undertreated or untreated physical illnesses, die prematurely, be homeless, be incarcerated, be unemployed or underemployed, engage in binge substance abuse, live in poverty, and report lower quality of life than people without such illnesses. The impairments associated with SMI, along with related factors such as poverty, stigma, unemployment, and inadequate housing, can significantly impact quality of life and can cause people with SMI to live in a “parallel universe” separate from people who do not have SMI. Symptoms or socially inappropriate behaviour caused by SMIs can cause others to reject the patient and refuse friendship, housing, or employment. Serious Mental Illness Across the Lifespan SMI occurs in people of any gender, age, culture, or geographical location. However, the population of people currently living with SMIs can be separated into two groups who have had different experiences with the mental health care system: (1) those old enough to have experienced long-term institutionalization and (2) those young enough to have been hospitalized only for acute care during exacerbations of their disorders. Some of today’s older adults with SMI have experience with a paternalistic or custodial system of care. They have learned that they are just to accept the treatment team’s decisions. Today’s emphasis on client-centred care, which requires the patient to express his or her opinions and wishes, challenges some older adults who grew up in the paternalistic institutions of the past. People young enough never to have been institutionalized usually do not have problems of passivity and dependency. Treatment via a series of short-term hospitalizations has given them limited experience with formal treatment and has contributed to some patients’ not truly believing a problem exists. Individuals who do not understand that they are ill, perhaps because of the impairment of the illness itself (anosognosia), are at particular risk for additional problems. Young adults with SMI, for example, are at particular risk for additional problems such as legal difficulties, substance abuse, and unemployment. Development of a Serious Mental Illness SMI has much in common with chronic physical illness: the original problem increasingly overwhelms and erodes basic coping mechanisms and increases the use of compensatory processes. As the disorder extends beyond the acute stage, more and more of the neighbouring systems are involved. For example, a person with schizophrenia may experience disturbed thought processes and social skills, which cause interactions with others to become increasingly awkward and anxiety provoking for both parties. This awkwardness, in turn, results in others’ becoming increasingly hesitant to interact with the affected person and in the affected person’s self-esteem weakening. Careful assessment can detect early signs of exacerbation and lead to intervention that decreases the severity of the exacerbation and its disruption of the person’s life. Recovery addresses life and living and inclusion for people with SMI. Rehabilitation Versus Recovery: Two Models of Care The concept of rehabilitation, which focused on managing patients’ deficits and helping them learn to live with their illnesses, dominated psychiatric care for many years. The recovery model is hopeful, empowering, and strengths-focused, with staff assisting the consumer to use strengths to achieve the highest quality of life possible. Issues Confronting Those With Serious Mental Illness Establishing a Meaningful Life Finding a way to reset one’s goals so that meaning can be found in new ways is important in achieving optimum quality of life and avoiding despair. Co-Morbid Conditions Physical Disorders One of the strategic directions of the Mental Health Commission of Canada (MHCC) is to achieve an “increase [in] the life expectancy of people living with severe mental illnesses.” Ideally, there needs to be collaboration between the psychiatric team and the primary care provider. Multiple studies indicate there is a higher risk for certain medical disorders. Depression and Suicide People with SMIs may experience a profound sense of loss of their pre-illness life and potential. This can lead to acute and chronic grief that contributes to the suicidal risk. Suicide occurs in 5% to 10% of those with SMI. Substance Abuse Many individuals with SMIs also have substance abuse problems (concurrent disorder). Clinical implications of substance abuse among people with SMI include poor medication adherence, increased suicide rates, increased violence, homelessness, worsening psychotic symptoms, increased HIV infection, and so on. Social Problems Stigma, Isolation, and Loneliness Studies show that individuals with mental illness expect and fear rejection, which increases their tendency to withdraw from society. For many patients, the stigma is worse than the symptoms of their SMI. Victimization Mentally ill people are more likely to be victims of violence than perpetrators. Their vulnerability may contribute to this significant problem. Economic Challenges Unemployment and Poverty According to the MHCC (2013), between 70% and 90% of people with SMI are unemployed, and 50% of those with SMI do not receive sufficient income from their disability entitlements. It can be difficult to find an employer open to hiring a person with SMI, and laws to prevent discrimination do not guarantee a job. Medications can be extremely expensive, along with cost of insurance and added co-pays. Housing Instability Housing is the first need of seriously mentally ill people. Owing to poor communication skills, cognitive problems, and other symptoms, people with SMI become homeless. Adults with SMI are increasingly using temporary homeless shelters, jails, and prisons as housing resources. Life on the street has a negative effect on an individual’s self-esteem. Safe, affordable housing is critical if people with SMIs are to maintain themselves within the community. Caregiver Burden Caregivers have limits in terms of coping with the persistent and challenging needs of people with SMI and may find themselves unable to shoulder the burden. Treatment Issues Nonadherence At any point in time, nearly half of all people with mental illness are not receiving treatment or are nonadherent to treatment, thereby potentially doubling the likelihood of relapse. Many reasons for medication nonadherence exist, among them cost, distressing side effects, and confusion about how to take the medication. Other problems include a disparity between treatment standards and what clinicians actually prescribe, and failure to adequately monitor long-term side effects. A solution to the latter is to have patients followed by nurses or physicians rather than social workers. Anosognosia Anosognosia is the inability to recognize one’s deficits due to one’s illness. Medication Adverse Effects Addressing adverse effects is essential to preventing nonadherence and maximizing quality of life. Treatment Inadequacy It has been suggested that there are significant gaps between the quality of mental health care provided and optimal care. Many treatment options have varying effectiveness, and patients and nurses must pursue a variety of alternatives and observe for changes or treatment inadequacies. Residual Symptoms Residual symptoms do not improve completely or consistently with treatment. Relapse, Chronicity, and Loss The majority of patients with SMI face the possibility of relapse even when adhering to treatment, which may contribute to hopelessness and helplessness. Resources for People With Serious Mental Illness Comprehensive Community Treatment • The goal of community-based health care programs is to provide broad community mental health services that will prevent psychiatric hospitalization, maintain stability in a community setting, and achieve the highest possible level of functioning. Various services include: Adult outpatient services, which provide evaluation for possible psychiatric hospitalization, initiate treatment, respond to crisis calls and walk-in requests for service, offer group and individual psychotherapy, and coordinate psychiatric emergency responses with hospitals, police, and other community service providers Day care services, which provide alternatives to 24-hour care Case managers to serve as coordinators to ensure integration and cooperation of various elements of the system and act as advocates for patients in the system Regional outpatient clinics, which provide therapeutic and rehabilitative services for patients with concurrent disorders or substance abuse Outreach and case management services, which provide care for people with SMI who are homeless by sending workers into streets, parks, shelters, bus stations, beaches, and anywhere mentally ill people are found Evidence-Informed Treatment Approaches Assertive Community Treatment In the ACT model, the patient works with a multidisciplinary team of professionals who provide a comprehensive array of services. Cognitive-Behavioural Therapy CBT identifies cognitive distortions and negative self-talk and guides patients to substitute more effective forms of thinking. Cognitive-behavioural strategies have been used to treat hallucinations, delusions, and negative symptoms. Common strategies include distraction when auditory hallucinations occur and reframing or verbally challenging delusional beliefs. Cognitive Enhancement Therapy CET involves 60+ hours of computer-based drills and exercises that incrementally challenge function, such as attention, processing and recalling information, and interpreting social and emotional information. Family Support and Partnerships Patient and family understanding of the disease process is vital. Concerns that should be addressed include safety, communication, medication adherence, symptom and behaviour management, and resources for respite and day care. Written instructions should be given in addition to oral instructions, and supportive follow-up by phone or home visits should occur to help patient and family deal with the burden, stigma, and isolation related to mental illness. The psychoeducational model has five basic aims. The treatment team must: (1) develop a genuine working relationship with family and other supportive people; (2) develop a structured and stable teaching plan that meets patient and family needs (e.g., medication teaching, signs of relapse, available treatment centres, available support groups); (3) minimize family tendency to be self-critical and demoralizing; (4) develop step-by-step communication and problem-solving skills; and (5) help the family develop a network of involved, understanding, and supportive people and resources. Social Skills Training Social skills training involves using a variety of learning techniques to teach patients discrete skills, such as independent living skills, conversation skills, dating, job seeking, affect regulation, and so forth. Supportive Psychotherapy Supportive psychotherapy focuses on supporting the patient at the current stage of illness rather than confronting possible problems and pushing the patient towards change. Vocational Rehabilitation and Related Services Studies show that patients with SMI who completed a vocational rehabilitation program demonstrated significant improvement on measures of assertiveness, work behaviours, and decreased depression and thereby improved income and employment status. Other Potentially Beneficial Services or Treatment Approaches Consumer-Run Programs Consumer-run programs range from informal “clubhouses,” which offer socialization, to competitive businesses such as snack bars or janitorial services. Wellness and Recovery Action Plans Wellness and recovery action plans are psychoeducational programs that empower and train consumers in skills that promote recovery and prepare them to deal with stresses and crises. Exercise and Outdoor activity Exercise improves the ability to cope with symptoms, reduces anxiety and depression, and enhances self-esteem and general health. Nature activity is proving to be an effective treatment approach to improve quality of life. Nursing Care of Patients With Serious Mental Illness Assessment Strategies Table 31-1 lists potential nursing diagnoses that apply to the patient with SMI. Table 31-2 lists examples of specific nursing outcomes from Nursing Outcomes Classification (NOC). Intervention Strategies Nurses use the following basic interventions with psychiatric mental health patients: crisis intervention, health teaching, psychobiological interventions, counselling, case management, milieu therapy, promotion of self-care activities, and psychiatric rehabilitation. Case managers provide entrance into the system of care and coordinate a wide range of community support and rehabilitative services, including food, shelter, and clothing needs. Case managers supply crisis stabilization to prevent relapse and hospitalization. Box 31-2 outlines two relevant Nursing Interventions Classification (NIC) interventions for the management of SMI. Current Issues Involuntary Treatment Involuntary treatment can involve both inpatient and outpatient settings. Traditionally, this situation involved involuntary inpatient admissions, but beginning in the 1990s, provinces began to experiment with community treatment orders (CTOs), which provide mandatory treatment in a less restrictive setting. Criminalization of Mentally Ill People Treatment of Mentally Ill by Police 1. In Canada, the number of incarcerated offenders with mental illness continues to increase; it is now estimated that 25% of newly admitted offenders have a mental illness. Unfortunately, adequate treatment does not always occur within the criminal system or in follow-up. Further, considerable concerns are raised about the treatment of crisis behaviour and people with SMI by police. Advocates instead seek additional training and diversion from jail to clinical care. Two interventions to achieve this end include the following: Educating police so they can identify mental illness, distinguish it from criminal intent, and connect people with SMI to help instead of jailing them. Establishing mental health courts that are designed to intercept people whose crimes are secondary to mental illness and that feature specially trained officials with authority to order treatment instead of imprisonment. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400