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Understanding Mental Health in Older Adults

Understanding Mental Health in Older Adults
Gabrielle Juliano-Villani, LCSW
January 24, 2023

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Editor’s Note: This text is a transcript of the course, Understanding Mental Health in Older Adults, presented by Gabrielle Juliano-Villani, LCSW

Learning Outcomes

After this course, participants will be able to:

  • Describe the intersection and prevalence of mental health disorders among older adults and the elderly.
  • List the criteria for common mental health disorders.
  • Identify the symptoms of common mental health disorders and when to refer a client for help.

What is Social Work

I'm not going to talk too much about social workers and what we do. I did a different course on SpeechPathology.com a couple of months ago that you can view for more information on how social workers and SLPs can work together (Course 10051). To give just a brief understanding of what we do, we are a profession that is dedicated to helping people function the best they can in their environment. That's a pretty broad definition, but it's a pretty good definition of what we do. We address the needs of society and we bring them to the public's attention. We help our clients, the community, and families solve and cope with problems.  We do a lot of advocacy work as well.

Social workers have many different roles and work in many different places.  We can be case managers and therapists (if licensed). You might see us in community agencies, community mental health, doctor's offices, hospitals, and hospice. 

As far as the elderly, the most common place that you'll see us working is in palliative care, long-term care or skilled nursing facilities, hospitals, acute rehab centers, and hospice. We do a lot of care management and case management, private practice, adult protective services, and child protective services. I always like to include child protective services because even if your client is a child, their caregiver might be an older adult. And of course, that can impact the care that your client is getting.

Older Adults and the Elderly

When I work with older adults and the elderly, I usually ask my client what they prefer to be called before I start calling somebody a "senior." But for our purposes, elderly typically refers to somebody who's 65 and older. Although my mom who is 66 would be upset if I refer to her as elderly, she thinks she's a senior. So ask your client what they prefer to be called.

Older adults and the elderly comprise a very large portion of the US population. In 2014, 46.3 million people were 65 or older, and that number will keep growing, as you probably know.

Aging adults experience a higher risk of chronic disease, with 60% of older adults managing two or more chronic conditions. This is important because chronic health conditions and mental health disorders are closely tied together. As we get older, the risk of getting a chronic health condition increases because of lifestyle changes, our bodies getting older, et cetera. A chronic health condition typically lasts for a year or more. It impacts activities of daily living and functioning, and it requires ongoing medical attention.

According to the CDC,  six in 10 adults have one chronic health condition, and four in 10 adults have two or more.  Of course, having a chronic health condition leads to a lower quality of life, is a leading cause of death, and is the leading driver for healthcare costs and disability. Social workers focus on how we can make an impact by doing preventative work.

Below is a list of some chronic health conditions. I'm sure that you are familiar with many of them. Chronic health conditions are ongoing, there's no cure for them, and they impact activities of daily living.

COPD

Diabetes

Cancer

Chronic Pain Syndrome
Alzheimer’sALS
DementiaHeart Disease
LupusObesity
MSStroke
Arthritis 

Chronic Health Conditions and Mental Health Implications with Older Adults

As I mentioned, there is a connection between chronic health conditions and mental health, especially with older adults. Eleven percent of people with Alzheimer's, 17% with cardiovascular diseases, 27% with diabetes, 42% with cancer, and 51% with Parkinson's also have major depressive disorder. That's pretty significant that about half of people with Parkinson's also struggle with major depressive disorder. That is important to keep in mind as you work with clients who are older adults or who are being cared for by older adults.  Additionally, arthritis and depression are leading causes of disability. However, depression can be prevented, and there are certainly ways that we can intervene before somebody gets to the point where they are disabled because of it.

Seven out of 10 primary care physician (PCP) office visits are over concerns with chronic diseases. Think about how big of an issue that is.  The amount of money, resources, and time spent managing chronic health conditions. Many of the contributing factors to chronic health issues are preventative as well.

The association between depression and chronic disease is easily seen.  If a person is depressed and then is diagnosed with a chronic health issue, that chronic health issue will probably get worse because they're having depressive symptoms and they're not able to take care of themselves. Then the disease gets worse and progresses more quickly, and they get depressed because of that. It just cycles on and on.

It's also important to note that clients who have depressive symptoms are also twice as likely to have a stroke and four times as likely to have a heart attack. Again, this is an area where we can make a significant difference in preventing some things from happening that make our clients sick.

Having a mental health disorder like depression or anxiety is going to affect a person's ability to undertake some of those health-promoting behaviors. For example, if somebody is depressed, it's going to be a lot harder for them to take their medication every day, exercise every day, make sure that they're eating healthy every day, or work on their treatment plan with their SLP every day.

A mental health disorder also impacts caregiving in both directions.  A caregiver will probably burn out sooner if they are trying to care for somebody who has a chronic health issue and is depressed at the same time.  In that type of situation, the caregiver takes on even more caregiving responsibilities, and they get burned out.  That can also lead to their own depression or anxiety. Burnout and depression are very similar and go hand-in-hand quite often.  And, as you probably know, caregiving can be very taxing on a person.

Mental Health Statistics

Mental health problems are very common, and some general statistics are important to know. One in four older adults will experience a mental health problem like depression or anxiety. Also, the suicide rate for men 85 years and older is extremely high. It's 39% higher than that of any other age group. So, it's a very large risk factor for any male client who is also depressed or struggling with substance abuse. Many older adults struggle with substance abuse, which is most likely attributed to higher drug use rates among boomers compared with previous generations. It's a common coping skill for that population. If it is an issue, it's usually not something that they like to talk about, and there are not very many therapists or substance abuse programs focused on older adults. That's an issue in our industry. I live in Florida and we have tons of inpatient substance abuse programs. But I think that about two really focus on older adults. So, it's definitely an area we need to focus on and do some more research.

The most common mental and neurological disorders in this age group are dementia, anxiety, and depression. That's probably what you see, as SLPs, most often with your clients. There are also some more significant severe and persistent mental health issues (i.e., SPMI) in older adults, but we don't see them often, and they will not be the focus of this course. 

Risk Factors

As I mentioned, not many substance abuse programs work with older adults. There are also not a lot of psychologists or social workers who specialize in working with geriatrics, with only 1.2% of psychologists specializing in this area.  So, it is a big issue.  In social work, we get so many referrals for clients who are older adults because other therapists call and say they don't want to work with that population because they are viewed as difficult.  There's a big stigma around working with older adults. Therefore, there are very few providers who specialize in working with them.

It's important that elderly clients see someone who specializes in aging issues because they are obviously different from what young adults see daily. Many issues come up as far as death and end of life, losing mobility, getting diagnosed with a chronic health issue, losing independence, et cetera.

There is so much isolation and loneliness that these clients see, and people who are more isolated and have fewer social connections are at greater risk for developing dementia and depression. Of course, brain disease is also a risk factor that can lead to dementia and depression.

Bereavement is also a risk factor. If you are working with someone who's 90 years old, there's a good chance that they have experienced grief and loss. They might be dealing with a spouse who died as well.

Physical health greatly impacts mental health, as does a change in socioeconomic status due to retirement. We know that those factors are very closely connected. After someone retires, they're on social security, and their finances look much different than they did before. It can be a hard transition emotionally, but it can also be difficult regarding access to care. Social workers see a big gap in people on Medicare but don't qualify for Medicaid. They can't afford much of the care they need, but they make too much money to qualify for Medicaid, which will cover many of the things they need. 

Being female is a risk factor. Having a history of depression is also a risk factor. If someone has a history of mental health issues or a family member has a history of mental health issues, that individual has a higher risk of developing that mental health issue later in life as well.

If a person has misused drugs or alcohol, if they have a disability, and if they are sleeping poorly, that can lead to other mental health and health issues.

Depression

Depression is often seen in our older adult population. Six million adults over 65 in the US have depression, and the rate of depression increases with age. Of all my agency's clients, individuals with depression and trauma are probably seen the most.

We see a lot of anxiety too, which goes hand in hand with depression. Although the rate of depression increases with age, it's not a normal part of aging. Again, this is where we can intervene because older adults who are depressed visit the doctor and emergency room more often, use more meds, have higher outpatient charges, and have longer hospital stays. Social workers can make some big changes and help people live healthier lives.

Another issue for older adults is that they're less likely to report symptoms because of the stigma, especially with this age range of people with mental health. When we work with Gen Z or millennials, they're all about therapy. Older adults do not love therapy. It is important for SLPs, PTs, and OTs to understand mental health issues because you are seeing them first. You are usually their first line because they might have been in the hospital, and now you're seeing them through home health. They have a rapport with you, and they trust you.  If you see anything that looks like depression, start planting the seed of, "This is not normal. Some of the things that you report to me are concerning. I'm noticing that they're impacting your functioning. Would you want to talk to somebody?" That approach usually works a lot better with older adults. We get many referrals from home health -  PT, OT, SLPs- because you already have that established relationship with them, and they trust you.

There are a few different types of depression. We use the Diagnostic and Statistical Manual of Mental Disorders for diagnoses (social workers can diagnose, but we cannot prescribe medications). There are very specific criteria that include the following symptoms, although there are more listed in the DSM: 

  • Persistent sad, anxious, or “empty” mood
  • Loss of interest or pleasure in hobbies and activities
  • Feelings of hopelessness, pessimism
  • Feelings of guilt, worthlessness, helplessness
  • Decreased energy, fatigue, being “slowed down”
  • Difficulty concentrating, remembering, making decisions
  • Difficulty sleeping, early-morning awakening, or oversleeping
  • Appetite and/or unintended weight changes
  • Thoughts of death or suicide, suicide attempts
  • Restlessness, irritability
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

People can have depressive episodes. They can have a mild depressive episode, a moderate depressive episode, or even a severe one. Those with a severe depressive episode can have it with or without psychotic features. There's also Persistent Depressive Disorder which is a type of depression that does not get better.   

Older adults are often misdiagnosed because they have less obvious symptoms of depression. They are also less likely to report them because of the stigma or embarrassment. Usually, we hear a lot of, "I don't want to be a burden on somebody. I don't want anybody to worry about me," et cetera. 

Again, when you have that relationship with your client, you may see if it impacts their functioning or what their baseline looks like. Usually, the loss of interest in hobbies is pretty obvious. For example, I had a client who was 98 years old when I started working with her.  Even though she was so elderly, she was very active in her community. She was close with her neighbors. She was social and had a lot of hobbies that she liked to do, like crafts and quilting. She was referred to me because she started having these crying spells and her interest in her hobbies was completely non-existent. She refused to do any of her crafts or any social activities. That was a red flag for her granddaughter, who was her caretaker, that there might be something going on.

Sometimes it's hard to tease out whether there is a physical or a mental health condition. Therefore, it's important for us to collaborate with their primary care doctor or any other specialists that are involved in their care. Some of these symptoms, like a decrease in energy or fatigue, appetite, or issues with sleep, can be caused by a physical health issue.  It is not unusual for me to get a call from a primary care physician saying they have run every test, have tried everything, and there is nothing physically wrong with the person. That's usually when we know there is definitely some depression going on. If we can start some of our interventions and possibly some medication, we'll see some of those issues resolve.

Of course, if anybody has thoughts of death, suicide, or suicide attempts, that's very concerning.  This topic could be its own course. But thoughts of dying, wanting to die, or feeling hopeless are symptoms of depression. Often clients might not want to express that they're feeling this way because they're afraid they will be institutionalized. But it's a very typical symptom of depression to have those thoughts. Social workers can intervene and determine if this is a symptom of depression, if there is an actual plan that's taking place, or if they have had past attempts.

Another symptom that has some overlap is aches or pains, those physical symptoms. Many mental health issues can manifest as physical symptoms. For example, I may have a client with chronic pain, headaches, or GI problems. When we start working through some mental health issues, many physical symptoms will dissipate.

Anxiety

Anxiety is another very common symptom seen in older adults. It is mainly characterized by excessive fear and is related to behavioral disturbances. Fear is the emotional response to a real or perceived threat or immediate danger. It's our fight-or-flight response. Anxiety is the anticipation of that threat. So, a person might be "preparing" or have cautious or avoidant behaviors. Usually, people with anxiety like to avoid quite a bit.

Anxiety is also persistent. The person overestimates the danger because that's what our brains like to do. As a clinician, we can make the determination of what is excessive or out of proportion because sometimes it makes sense to worry about some of those things. But if it's totally out of proportion, we can work with the client to manage those feelings. Oftentimes, people who have depression also have anxiety. And, again, they are less likely to report the symptoms because of the fear of what could happen, they don't want to be a burden, or they don't think it's important.

Anxiety is very physical, and there is a big focus on the physical symptoms. If you have experienced or lived with anxiety or have had a panic attack, you understand what it feels like. It's very physical, it's very visceral. Sometimes people focus on those physical symptoms and do not understand that it's truly anxiety. That's where social workers can help.

Common Types of Anxiety Disorders

There are many different types of anxiety disorders. There is panic disorder, which is characterized by panic attacks, a sudden feeling of terror that come on without warning. There are a lot of physical symptoms, including shortness of breath, chest pain, dizziness, and heart palpitations. Sometimes we'll work with clients in the hospital because they think they're having a heart attack, but it was actually a panic attack.

PTSD also has components of depression and is characterized by persistent symptoms after a traumatic event. That traumatic event has to be specific, such as witnessing a death, violence, or threat to your safety. Common symptoms can include nightmares and flashbacks, depression, anger, irritability, or distractability. Again, symptoms can overlap with depression and anxiety so it is important for us, as therapists, to do our due diligence and get a clear history of any trauma that has occurred. We want to get a full intake with a client and get a sense of any trauma that might have occurred.  We might also do an ACEs (Adverse Childhood Experiences Survey) to gain insight into any past trauma. 

Phobias are another common type of anxiety, and there are a few different types. There is the natural or environmental type, which is a fear of lightning or water. Blood injection injury type would be fear of needles or surgery, going to the dentist or the doctor, and getting blood drawn.  Animal type is fear of dogs, snakes, and insects. Situational would include claustrophobia or a fear of flying. There are other types, such as choking, vomiting, or loud sounds. We don't see that quite as often, but they do exist.

Generalized Anxiety Disorder

The most common anxiety disorder is generalized anxiety disorder which is a chronic, exaggerated worry about everyday routine life events and activities. It has to last at least six months and is almost always anticipating the worst, even though there is little reason to expect it. It is expecting the worst-case scenario every single time for everything. Physical symptoms can include fatigue, trembling, muscle tension, headache, or nausea. 

Again, as the SLP, it's important for you to be aware of these symptoms because they impact the client's ability to work with you.  Sometimes when we get referrals from other people in the community or rehab, they're not doing what they're supposed to be doing, and we don't know why. I don't know why the patient isn't doing their exercises or following the plan. Oftentimes, it's because many of these things get in the way and their therapist might not realize it, and the client probably doesn't realize it either. But it can have a significant impact on everyday functioning. What is the impact of these symptoms on the person's functioning? Can this person who, for example, is having feelings of hopelessness still get up every day or are they laying in bed until 3:00 PM? That is the biggest thing we look at when diagnosing the impact on their functioning and what the client's baseline was previously.

With generalized anxiety disorder (GAD),  it's difficult to control the worry. The person feels like there's no control over it, it might be intrusive, it might be constant. They may not want to feel that way, but they do. "Every day when I get up, I'm worried that somebody's gonna break in and hurt me," for example. They can't get past that thought and it is, obviously, very exhausting. So, they might be easily fatigued, restless or on edge, or irritable. Three or more of those symptoms must be present for them to be diagnosed with generalized anxiety disorder.  

More examples: 

  • Persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events
  • Overthinking plans and solutions to all possible worst-case outcomes
  • Perceiving situations and events as threatening, even when they aren't
  • Difficulty handling uncertainty
  • Indecisiveness and fear of making the wrong decision
  • Inability to set aside or let go of a worry
  • Difficulty concentrating, or the feeling that your mind "goes blank"

Obsessive Compulsive Disorder (OCD)

Another common type of anxiety disorder is OCD. This is recurrent, unwanted thoughts (obsessions) or rituals (compulsions) that the person feels they can't control. Often time the rituals are performed in the hope of preventing obsessive thoughts or making them go away.  We also see a lot of what we call "Pure O," which are obsessions.  So, people can have OCD with recurrent, unwanted thoughts without the rituals. Typically, when we think of OCD, we think of somebody who has to lock the door three times or turn the lights on and off three times before they can do anything. 

But sometimes, it's just having very intrusive thoughts. An example is a client who was obsessing about death and was very concerned about dying. This person couldn't control it, and it was a constant thought. So it's important to make that delineation because it is a different type of treatment. If you have a client who has very obsessive thoughts and can't control them, or they tell you that they're having these recurrent unwanted thoughts, that might be a good time for you to make a referral and get a therapist involved.

Hoarding

Hoarding is not very common, but I have done home health visits with SLPs, PTs, and OTs as somebody who works with older adults. We see hoarding more than most people because we go into their homes.  We all have an idea of what hoarding is. It's having difficulty with giving away or parting with possessions and people experience significant distress when getting rid of those things. An excessive accumulation of possessions occurs regardless of value. So that's important to note, it doesn't need to be valuable. For example, someone hoards might have tons of newspapers stacked up.

Hoarding can be mild to severe. I have worked with clients who have mild hoarding, but it wasn't a safety issue. I could see that they were keeping things. There were piles of stuff, but you could walk through the house. There were pathways. Typically, the individual minimizes it or doesn't see it as a problem.

Some signs and symptoms include indecisiveness, perfectionism, and procrastination. There are a lot of problems with planning and organizing. They might feel a need to save items, even though they might not be worth anything. They may get very upset at the thought of getting rid of them. There is a lot of clutter, and it might be to the point where the rooms become very unsafe or unusable. This, of course, is a concern for older adults because of fall risks, or if there is an emergency like a fire and they can't get out.

Again, if you've worked with somebody who is hoarding, you've probably seen a lot of piles or stacks of things. There's no place to walk. They might be using a space for something else, or it's unusable for its intended purpose. For example, they can't get to the sink to do dishes. There might be a lot of unsanitary build-up of food or trash. There could be some functioning problems with keeping themselves or other people safe in the home and conflict with others who try to reduce or remove the clutter from the home.  These individuals have difficulty organizing things and also lose important things in the clutter.

In my experience, people who are hoarding have all been older and have experienced grief and loss. One individual I saw was in her late eighties and she had lost her daughter to cystic fibrosis about 20 years prior to meeting her.  She also had a miscarriage earlier in life. So those were two pretty significant losses that she had never worked through. Her house was more moderate to severe. It wasn't completely unsafe, but there were some issues. And she had fallen a couple of times, which was a problem.  The kitchen was pretty dirty and there were stacks of things everywhere. In particular, she had a lot of things saved from her daughter that had died, which to some people would seem really insignificant. For example, she had the little bags from the pharmacy that you get your prescription in, with her daughter's information on them. She'd been holding onto those for over 20 years and absolutely refused to throw them away. So, that was something we were working on because it was becoming an issue. The family was sent to collections. They weren't paying their bills on time because all of these things were getting lost. But the thought of throwing any of that away was very distressing to her.  To her, these things had important emotional significance, even though someone else might think it is trash and should be thrown away.  It was a reminder of her daughter. She even told me that she felt safer being surrounded by those things. So, it can be difficult for these individuals to work through their hoarding. But there is very specific training and interventions that we can do to work with those clients.

Dementia

Obviously, we see dementia a lot in older adults. As you know, it's not a specific disease, but more of a syndrome or a common term.  There are Alzheimer's and Parkinson's, and other types underneath the umbrella of dementia. It is not a normal part of aging. Some forgetfulness is normal, but dementia is not a normal part of getting older.

Fifty million individuals worldwide are living with dementia and nearly 60% live in low and middle-income countries. It's very pervasive. The total number of people who have it is projected to increase significantly in the next 20-30 years.  Most common symptoms are memory, attention, communication, and issues with judgment or problem-solving. There can also be visual disturbances, which can be a red flag to take a deeper look at what's going on with the person.

Some signs of dementia include using unusual words for familiar objects. For example, calling a clock a timekeeper. Not being able to complete tasks independently, forgetting the name of somebody who's close to them or a family member, or getting lost in a familiar area are additional signs of dementia that might require more testing.

There are many different types of dementia, and they all look slightly different. Somebody who has Lewy Body is not going to present the same as somebody who has Alzheimer's. Our interventions will be different for different types of dementia because they are all different.

Somebody with vascular dementia might have more behavioral issues than somebody with Alzheimer's. It's important to know that because some of the things that they might be experiencing could be seen as depression, but it's really dementia. There's a lot of overlap. Another example is somebody with Lewy Body might be having hallucinations, and they may be misdiagnosed as having schizophrenia or some other mental health issue. Obviously, the interventions for those diagnoses will look very different.

Fronto-temporal dementia can occur in younger people. I have seen it in an individual as young as 40 years old.  Individuals may have more behavioral symptoms compared to some other types of dementia.  There may also be an underlying physical cause.  It could be that their medication or a vitamin deficiency is making them act this way, which could then be reversible. But we know that dementia is degenerative.  It does not get better, and there's no cure.

Treatment for Dementia

I included the following because a lot of work with dementia is working with the caregiver or the family.  As I mentioned earlier, when people have Alzheimer's or dementia, there can be an overlap with depression. Even as professionals, we need to separate the person from the disease. They're not acting mean, it's just a symptom of their dementia. We want to keep those things separate. When working with caregivers and families, we spend a large amount of time reminding them that this is a symptom of the disease, it's not your actual mom or your dad that's acting this way towards you.

Coping Tips

Changing the environment may help resolve challenges related to comfort or ease of mind. For example, somebody might be acting difficult, but it's because the temperature in their room is too hot or too cold.  Paying attention to those little things can make a difference in somebody's functioning. 

We can also monitor their comfort. I talk with caregivers and families often about avoiding being confrontational or arguing about facts. I often hear comments like, "That's not how it happened. They're saying that our aunt Susie is alive and she's coming to visit but she died 20 years ago." We want to tell the caregiver or family member to let it go, redirect, and move on to the next thing.  Redirect their attention, and make sure that there's a calming environment if you can.

Allow rest between stimulating events. When working with people who have dementia, I'll make sure that I'm not scheduling them back-to-back with other appointments that they may have. And usually, they have a lot of appointments with home health and other people working with them. I want to make sure that the physical therapist isn't there, and then OT is coming, and then I'm coming, and then the caregiver is coming in the same afternoon. We can space things out so they're not getting agitated and worked up.

Grief and Loss

Grief and loss are among the most common things we see in older adults.  Remember, grief and loss are not just about people dying. We have grief and loss related to many different things, and it's personal and unique. There are a couple of definitions:

"An intense set of emotional reactions in response to a real, imagined, or anticipated loss." (Shupp, 2007)

“An intense emotional state associated with the loss of someone, or something, with whom, or which, one has had a deep bond. Not a synonym for depression." (Shupp, 2007)

Grief and loss are very different than depression, and they look different for every single person.  Every single person experiences grief. Again, it does not have to be the loss of a person.

Three Types of Grief

Grief can be real, which is existing or happening as a fact, such as a death or a tragedy.   It could be imagined, such as losing a monetary investment or not getting the promotion you were expecting.  And grief can be anticipated. We see a lot of anticipatory grief in older adults because they are preparing for an impending loss (e.g., death), a terminal illness, or a new diagnosis (e.g., dementia).

Social workers do a lot of work with patients on grieving their old life and accepting how life is now. Because obviously, if somebody has dementia or has been diagnosed with multiple chronic health issues, that's going to look a lot different compared to their life before. They've probably lost independence and mobility, they may have lost their job, and their relationships with their family and friends may have changed as well.

Complicated Grief

We also see complicated grief. This could be a whole other training, but complicated grief is a disruption in the normal grief process. It is also listed in the DSM as persistent complex grief disorder.  Of course, there is no timeline for grief or what it looks like. But complicated grief usually gets worse and not better. Typically when people are moving through grief, it's painful, but it might start to resolve itself. The person might be thinking about that loss only 70% of the time instead of 100% of the time. But with complicated grief, it starts to get worse. This type of grief is common with older adults because there are many risk factors that older adults have.  You will see much of that if you work with older adults. Obviously, they're grieving, but if you see some clients whose symptoms start to get worse, start to look like depression, or they're not taking care of themselves, then they may need a different intervention.

UTIs

Older adults get UTIs often, and can look a lot like a mental health issue when it's not. They don't always have the classic symptoms of UTIs, and I get referrals all the time that the person is hallucinating and psychotic. But, it's because they have a urinary tract infection. So, if you have clients that are prone to UTIs, have a history of UTIs, don't drink a lot of water, or have a catheter, make sure they also get treated for that. Make sure that it's not a UTI before assuming it is something else. Usually, there's also a lot of confusion. They might have had some recent falls. They may be lethargic. 

When to Refer

As the SLP, you may already have that trust, rapport, and relationship with the client. You can help get them to a better functioning level because they have that relationship with you. When referring to social work, always look at their baseline functioning. If you have a client you normally see in the morning, they're usually dressed and have had their coffee. Now you're noticing that they're still in bed, haven't been showering, are not cooking for themselves, or are not taking care of their animals. Those changes can be an indication of something else going on.  "Usually, you're up at 9:00 AM when I come and see you. You're ready to go and ready to work.  For the past two weeks, you've still been in bed. What's happening?" Hopefully, they can share with you what's going on. Try to get more information and explore that with them. Do they feel like it's normal? Do they feel like, yes, there is something else going on, and I need more help to work through it?

Treatment

There are many different types of treatment in social work. Social workers can't prescribe medications, but we can refer patients to a psychiatrist who hopefully specializes in this population.  Some PCPs don't like to prescribe SSRIs and psychotropic meds. But medication can make a big difference. I often hear from older adults, "It's supposed to be this way. I'm old, and it is what it is.  That's it." But the truth is that it doesn't have to be that way every day. Someone in their 80s could live for another 10 or 20 years. Do you want to spend every day feeling hopeless or worrying so much that you can't leave your house? It doesn't have to be that way.

There's a stigma, especially with this age group getting therapy, that change can be slow. Unfortunately, that can be frustrating for other people in this field who don't want to work with older adults because change is slow and sometimes small. But it's very rewarding and worthwhile. If family therapy is appropriate, we can always do that. Usually, by this time in somebody's life, there might be some estrangement or some relational issues that are going on that might need to be worked through. Sometimes people want to work through that before they die, so that also comes up.

Group therapy can be great for people diagnosed with dementia, Alzheimer's or cancer. In a group, a person can get and give support, which can be very rewarding. Different types of psychotherapy can help.  It depends on the therapist, the client's orientation, and what works best for them. I am very eclectic in my approach and do a couple of different things with people. I'm an EMDR therapist. So I work a lot with trauma and do a lot of mindfulness. But some therapists are very behavioral-based, and they'll do cognitive behavioral therapy (CBT), which can be helpful. Life review is also very helpful for older adults. Life review may seem simple, but therapists can use that information to make sense of what's happened in a person's life and what's happening now. 

Mindfulness

Mindfulness is being aware of one's surroundings without judgment.  This is my favorite thing to do with all of my clients, and I might explain mindfulness differently to older adults who might be a little resistant to it. It's not the same as meditation. Although meditation is a type of mindfulness. It's being aware of their surroundings without judgment, and it can be done so many different ways, such as body scans, Progressive Muscle Relaxation, deep breathing, and imagery, 

Cognitive Behavioral Therapy

I discussed CBT earlier. It helps clients or caregivers look at thoughts, identify distortions, and modify them into more helpful and accurate thoughts. We see this a lot with anxiety. CBT usually works well with anxiety because of those intrusive thoughts that may or may not be true, that worst-case scenario. 

Support Groups

Support groups are not just for clients but for their caregivers or family. Again, support groups are not just for getting support but also giving support.  It feels good to connect with others who are going through similar situations, and they can share that connection with them. Support groups are also great for getting different ideas or education on managing things, what's normal, what's not, and what to expect.

Life Review

With life review, an individual talks about their life or shares some life stories. We look at positive experiences to help them feel important and useful. We look at what they've been through and what they've come through to see how that influences them now or then. We also look at any past conflicts or issues so that they can resolve some of that too.

Caregivers and Caregiver Burnout

Caregivers can be family or private duty.  Caregivers are at increased risk for negative health consequences, including stress and depression, and need increased support to preserve their own health. These risks are greater for caregivers of people with Alzheimer’s and related dementias. 

Caregiver burnout is physical, mental, or emotional exhaustion, and some signs of burnout are: 

  • Role confusion - You may feel confused about being a caregiver. It can be hard to separate this role from the one of spouse, child, or friend.
  • Unrealistic expectations - You may expect your care to have a positive effect on the health and happiness of the person you care for. This may be unrealistic for patients who have a progressive disease such as Parkinson's or Alzheimer's.
  • Lack of control - It can be frustrating to lack the money, resources, and skills to manage your loved one's care well.
  • Unreasonable demands - You may take on too much, partly because you see providing care as your job alone.
  • Other factors - You may not recognize when you’re burned out and get to the point where you can’t function well. You may even get sick yourself. (WebMD, 2021)

Ethical and Cultural Considerations

It's always important to consider cultural considerations, especially with older adults. We want to look at their cultural beliefs and traditions and any religious or spiritual considerations because what we think a client should be doing or how they should be monitoring their health might be very different. We must be sure we empower them and allow them to make those decisions within their own cultural context.

Questions and Answers

When people age and their social circles change because their friends are dying, does that make depression more normal or at least more common? Similarly, after a major health event, like a stroke, how do you know when it's depression versus a normal grieving process? 

Yes, that's very common, especially when it comes to losing friends. It's normal to be sad and have some depressive symptoms surrounding that. But when somebody has a true depressive episode, that's not normal. Feeling sad over a situation, having some time where you're feeling hopeless or having tearful spells is normal. But if that lasts for a period of time, that's when we start ask if something else could be going on.

But it's hard because who isn't depressed when somebody dies or there's a big change in your health? So it's really looking at the impact on functioning. We also have specific criteria in our DSM to look at as well.  There has to be a certain amount of symptoms lasting for a certain amount of time.

You mentioned that caregivers may be experiencing burnout, depression or anxiety as well as the patient. Where would you refer a caregiver, especially one who doesn't have insurance or a primary care physician?

There are tons of caregiver groups out there and a lot of them are free. Hospice, palliative care, and hospitals are good places to start. I would also look in your area on aging as most places have something like that. There are a lot of community resources. You can literally Google, "Denver, Colorado area on aging," and it'll list resources that those people can get connected to. If they're caregiving for somebody with a specific illness like Alzheimer's or Parkinson's, those associations have caregiver support groups also. They usually have care managers who are social workers who can help them get connected to more resources.

Citation

Juliano-Villani, G. (2023). Understanding Mental Health in Older Adults. SpeechPathology.com. Article 20563. Available at www.speechpathology.com

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gabrielle juliano villani

Gabrielle Juliano-Villani, LCSW

Gabrielle Juliano-Villani is a licensed clinical social worker with over 15 years of experience in the field of mental health and is the owner of Colorado In-Home Counseling, a private group practice that focuses on providing psychotherapy services to older adults and adults who struggle with aging, grief and loss, caregiver stress, burnout, chronic health issues, anxiety, and depression.



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