CHAPTER 22 MENTAL

HEALTH
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OBJECTIVES
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 responses.
Recognize older adults who are at risk for suicide, and use appropriate
techniques for suicide assessment and interventions.
Specify several indications of substance abuse in older adults, and discuss
appropriate nursing responses.
Evaluate interventions designed to promote mental health and wellness in
older adults.

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QSEN
Patient-Centered Care
o Assessment p. 341-342, 345-346, 348, 350-351, 354-355, 357-358
o Interventions, p. 342-343, 346, 347, 348, 351, 355, 358-359
o Box 22-1: Interventions for Anxiety in Older Adults, p. 343
o Box 22-2: Clinical Examples of PTSD in Older Adults, p. 344
o Box 22-3: Risk Factors for Depression in Older Adults, p. 350
o Box 22-4: Suggestions for Encouraging Reminiscence, p. 352
o Box 22-5: Interpersonal Support by Family and Professionals, p. 353
o Box 22-6: Suicide Risk and Recovery Factors, p. 355
o Box 22-7: Signs and Symptoms of Potential Alcohol Problems in Older Adults, p. 357
o Box 22-8: Adapting Alcohol Treatment Interventions for Older Adults, p. 358
• Evidence-Based Practice
o Evidence-Based Practice Box 22-1: Mental Health Disorders in Older Adults, p. 344

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THEMES & CONCEPTS
 THEME: Personal Preferences
 Concept: Culture
o Exemplar: Ethnic and Cultural Considerations, p. 349

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 THEMES & CONCEPTS,


CONT.
THEME: Cognitive Function
Concept: Cognition
o Exemplar: Mental Health Disorders, p. 341

o Exemplar: Anxiety Disorders, p. 341

o Exemplar: Obsessive-Compulsive Disorder, p. 345

o Exemplar: Paranoid Symptoms in Older Adults, p. 345

o Exemplar: Delusions, p. 345

o Exemplar: Hallucinations, p. 345

o Exemplar: Schizophrenia, p. 346-347

o Exemplar: Bipolar Disorder, p. 347-348

o Exemplar: Depression, p. 348-350

o Exemplar: Box 22-3: Risk Factors for Depression in Older Adults, p. 350

o Exemplar: Differing Presentation of Depression in Elders, p. 350

o Exemplar: Suicide, p. 354

o Exemplar: Box 22-6: Suicide Risk and Recovery Factors, p. 355

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THEMES & CONCEPTS,
CONT.
 THEME: Maladaptive Behavior
 Concept: Addiction
o Exemplar: Substance Misuse and Alcohol Use Disorders, p. 355-357

o Exemplar: Alcohol, p. 355-357

o Exemplar: Acute Alcohol Withdrawal, p. 359

o Exemplar: Other Substance Abuse Concerns, p. 359-360

o Exemplar: Box 22-7: Signs and Symptoms of Potential Alcohol Problems in Older Adults, p. 357

o Exemplar: Box 22-8: Adapting Treatment Interventions for Older Adults, p. 358

 THEME: Attribution and Roles of Nurse

 Concept: Health Promotion
o Exemplar: Health People Box 22-1: Mental Health and Mental Disorders (Older Adults), p. 339

o Exemplar: Health People Box 22-2: Substance Abuse Objectives for Adults, p. 356

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MENTAL HEALTH CONSIDERATIONS

Mental health is the same later in life as it is earlier in life except that the
challenges may be greater.
Interference can occur as a result of:
 Developmental transitions
 Life events
 Physical illness
 Cognitive impairment
 Situations calling for psychic energy

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MENTAL HEALTH
CONSIDERATIONS—CONT’D
Most older adults manage transitions and stressors through resilience,
hardiness, and resourcefulness.
Those that are not successful have:
Lack of social supports
Accumulated stressors
Unresolved grief
Preexisting psychiatric illness
Cognitive impairment
Inadequate coping resources
Those most at risk have life transitions and a loss of social support.

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MENTAL HEALTH
CONSIDERATIONS—CONT’D
Those 55 years of age and older will experience mental health disorders
that are not typically part of normal aging:
Long-term consequences of military conflict
Twentieth century drug culture
Mental health disorders are typically underreported and not well
researched, especially among racially and culturally diverse people.
https://www.youtube.com/watch?v=l3SmWyhkKjI
https://www.youtube.com/watch?v=QWQ-P1LjpRQ

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FACTORS INFLUENCING
MENTAL HEALTH
Attitudes and beliefs CARE
 63% of older adults with mental health disorder do not receive services
 Older people reluctant to seek help because
 Pride of independence
 Stoic acceptance of difficulty
 Unawareness of resources
 Fear of being “put away”

Settings of Care
 Wide range of settings including
 Acute and long-term inpatient psychiatric units
 Primary care
 Community and institutional settings
 Residential care in nursing homes, assisted living facilities

Cultural and Ethnic Disparities

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MENTAL HEALTH DISORDER:
ANXIETY DISORDER
Anxiety is a normal human reaction and part of the fear
response.
When anxiety is prolonged, exaggerated, and interferes with
function, a problem occurs.
Anxiety disorders are not part of normal aging.
Chronic illness, cognitive impairment, and emotional loss may
contribute to anxiety.
Types of anxiety disorders include generalized anxiety disorder,
phobic disorder, obsessive-compulsive disorder (OCD), panic
disorder, and posttraumatic stress disorder (PTSD).

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PREVALENCE OF ANXIETY DISORDERS

Are common in older adults but are rarely diagnosed in clinical practice.
Older adults rarely report or acknowledge anxiety and attribute symptoms to
physical health problems.
Symptoms are behaviors such as agitation, irritability, pacing, crying, and
repetitive verbalizations.
Anxiety is often the presenting symptom of depression.

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RISK FACTORS FOR ANXIETY DISORDERS

Women
Urban living
History of worrying or rumination
Poor physical health
Low socioeconomic status
High-stress life events
Depression
Alcoholism

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IMPLICATIONS FOR GERONTOLOGICAL
NURSING AND HEALTHY AGING
Older adults deny psychological symptoms.
Anxiety-related symptoms are attributed to physical illness.
Older adults have co-existent medical conditions that mimic
symptoms of anxiety.
Side effects are common with prescribed and over-the-counter
medications.
Assessment of anxiety in older adults focuses on physical,
social, and environmental factors.
Treatment preferences include nonpharmacological
interventions, but medications are taken.

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POSTTRAUMATIC STRESS DISORDER
Symptoms of PTSD develop after an extremely traumatic event
that involves witnessing, hearing about it unexpectedly, and actual
or threatened death or serious injury to self or another closely
affiliated person.
Symptoms include helplessness, flashbacks, intrusive thoughts,
memories, images, emotional numbing, loss of interest, avoidance
of any place that reminds the person of the traumatic event, poor
concentration, irritability, startled reactions, jumpiness, and
hypervigilance.

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SYMPTOMS OF POSTTRAUMATIC
STRESS DISORDER
Sleep problems
Somatic disturbances
Anxiety
Depression
Restlessness
Older adults who have a higher rate of physical conditions and physical
functioning

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ASSESSMENT AND INTERVENTIONS

Knowing an older adult’s history and life experiences is essential to treat

PTSD.
Successful coping is associated with:
 Freedom of expression of events
 Favorable circumstances immediately after trauma
 Strong faith, religion, and hope
 Sense of humor
 Biological integrity

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OBSESSIVE-COMPULSIVE DISORDER

OCD is the performance of recurrent and persistent thoughts, impulses, or

images that are repetitive and purposeful.
Intentional urges of ritualistic behaviors improve the comfort level and are
recognized as excessive and unreasonable.
Impairs one’s function and consumes more than 1 hour a day.

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PARANOID SYMPTOMS
IN OLDER ADULTS
Can signify an acute change in mental status as a result of a medical illness
or delirium.
Paranoia is an early symptom of Alzheimer disease, appearing
approximately 20 months before diagnosis.
Precipitating factors include vision and hearing loss, social isolation,
alcoholism, depression, presence of negative life events, financial strain, and
PTSD.

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DELUSIONS

Are beliefs that guide one’s interpretation of events and help make sense out
of disorder, although they are inconsistent with reality.
Common delusions are being poisoned, children taking their assets, being
held prisoner, or being deceived by a spouse or loved one.

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HALLUCINATIONS

Are sensory perceptions of a nonexistent object.

Become evident when one is feeling alone, abandoned, isolated, or
alienated.
Are in response to physical disorders.

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SCHIZOPHRENIA

Is characterized by two or more of the following: delusions, hallucinations,

disorganized thinking, disorganized or catatonic behavior, flat affect, poverty
of speech, or apathy, which causes significant social or occupational
dysfunction.
Onset occurs between adolescents and adults 30 years of age but extends
into older adulthood.

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BIPOLAR DISORDER

Is not common in later life.

Is seen in older adults, 60 to 64 years of age.
Mania, versus depression, is more frequently the cause of hospitalization.
Lithium is the treatment of choice with another mood stabilizer added.

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DEPRESSION
Is common in later life and most treatable; however, it can be life
threatening if left unrecognized and untreated.
Is the major reason older adults are admitted to nursing homes.
Becoming depressed doubles the probability of becoming sick.
Is underdiagnosed and undertreated in older adults.
Failure to treat increases morbidity and mortality.
https://www.youtube.com/watch?v=Jpq0Sn0Tqy4

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CAUSES OF DEPRESSION
Contributing factors: health, gender, develop-mental needs,
socioeconomics, environment, personality, losses, and functional
decline
Medical disorders: cancer, cardiovascular disorders, endocrine
disorders, neurological disorders, metabolic disorders and
nutritional, or viral infections
Medications
Alcohol abuse, loss of spouse or partner, decrease in income,
caregiver stress, and gender

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SYMPTOMS OF DEPRESSION
Physical symptoms
Insomnia
Loss of appetite and weight loss
Memory loss
Chronic pain
Hypochondriasis
Decreased energy and motivation, hopelessness, increased
dependency, poor grooming, withdrawal from people, decreased
sexual interest, “giving up”

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THERAPEUTIC INTERVENTIONS

Reminiscence and life review

https://www.youtube.com/watch?v=bktozJWbLQg
Medications: antidepressants
Observation for side effects

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SUICIDE

Rates are higher in older adults than in any other population group.
Those 85 years of age and older make up the largest group.
Common precipitants include physical or mental illness, death of spouse or
partner, and substance abuse.
Use of firearms in older men is the lethal method.
Older adults rarely threaten suicide, they just do it.

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SUBSTANCE ABUSE: ALCOHOL
Is a coping mechanism in response to loss, anxiety, depression,
boredom, or pain associated with chronic illness.
Illicit drugs such as cocaine and heroin are becoming more
common in aging baby boomers.
Heavy drinking is the most common form of alcohol abuse in
older adults.
Men are four times more likely than women to abuse alcohol.
Women are more vulnerable to the effects of alcohol.

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SUBSTANCE ABUSE: ALCOHOL—CONT’D

Older adults have more adverse reactions as a result of their prescribed

medications.
Men are four times more likely to abuse alcohol.
Women are more susceptible to the effects of alcohol because they have
less body water, less mean muscle mass, and lower enzymes than men to
break down alcohol.
Alcohol abuse in women goes undetected until consequences occur.

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DRUG EFFECTS

Medications that the older adults take for chronic illness can have adverse
effects when combined with alcohol.
Urinary incontinence, gait disturbances, peripheral neuropathy, depression,
suicide, sleep disturbances and insomnia, and dementia or delirium can
occur with alcohol abuse in older adults.

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IMPLICATIONS FOR GERONTOLOGICAL
NURSING AND HEALTHY AGING
Assessment includes screening for alcohol abuse.
Alcohol-related problems may be overlooked.
Alcoholism is a disease of denial and not easy to diagnose.
Older adults may not view alcohol use as harmful.
Interventions are a stepped-care approach.
Clients will experience delirium tremens after alcohol withdrawal.

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OTHER SUBSTANCE ABUSE

Prescription and over-the-counter medications can be misused.

Older adults can become dependent on sedatives, hypnotics, or anxiolytic
medications.
Older adults may not be informed of the side effects of medications.
https://www.youtube.com/watch?v=ptYF6XqXxSI
https://www.youtube.com/watch?v=UV61Y0izGIQ

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QUESTION

Suicide is a consequence of the depressed older adult client if adequate care is not
obtained. Which older adult group is at the most risk for suicide?

A.60 to 68 years of age

B.69 to 76 years of age
C.77 to 84 years of age
D.85 years of age and older

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REFERENCES
Touhy, T.A., & Jett, K.F. (2014). Ebersole and Hess'
Gerontological Nursing & Healthy Aging (4th ed.).
St. Louis, Elsevier.
Touhy & Jett Powerpoint
www.youtube.com
www.consultgerirn.org

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