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SENIORS. WHAT DO YOU NEED TO KNOW? Lynne Nash, MSW, RSW Geriatric Mental Health Consultant Geriatric Mental Health Consulting Services Calgary Health Region. WHY DO WE NEED TO KNOW ABOUT SENIORS?.

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seniors

SENIORS

WHAT DO YOU NEED TO KNOW?

Lynne Nash, MSW, RSW

Geriatric Mental Health Consultant

Geriatric Mental Health Consulting Services

Calgary Health Region

slide3
Between 2006 and 2026, the number of seniors in Canada will increase from 4.3 million to 8 million. - www.alive.com, Oct/07 issue of Alive Magazine
slide4
In 1991, people aged 65 and older made up 12% of the Canadian population. By 2011, this number will rise to almost 22%.By 2031, there will be approximately 9 million seniors, and they will account for 25% of the total population.Healthy Aging in Canada,p. 7
slide5
The average life span is increasing in Canada – 100 years ago, the average life span was 78.3 years. It is now 84.2 years. www.alive.com, Oct/07 issue of Alive MagazineThe 85+ group is growing 4x faster than any other segment of the population
slide6
From 1991 to 2001, the percentage of Canadian seniors aged 80+ increased by 41% to 932,000. By 2011, it is expected to have increased another 43% to 1,300,000, the majority being women.Healthy Aging in Canada,p. 7
slide7
In the coming decades, seniors will comprise a larger share of the Canadian population, growing from 3.5 million people in 1996 to an estimated 6.9 million by 2021.
  • www.phac-aspc.gc.ca
slide8
By 2015, there will be more Canadians aged 65 or older than children under the age of 15Healthy Aging in Canada, p. 7
slide9
There are presently over 250,000 seniors with dementia in CanadaThis number is expected to rise to 778,000 by 2031There will be over 60,000 new cases of dementia in Canada each yearuntil then RNAO, 2003
slide10
“New diagnostic approaches which are detecting Alzheimer’s disease at earlier stages, the addition of the ‘baby boom’ numbers to the aging population, and the increasing incidence of the risk factors for Alzheimer’s disease are causing a striking increase in the number of younger people who are being diagnosed with the disease.”Alzheimer’s Society, 2006, p. 1
slide11
By 2011, almost 12,000 people in the Calgary Health Region will require access to services for dementia-related concernsThis number exceeds the total number of clients currently using home care servicesCHR
slide12
Although most seniors enjoy good mental health, at least 20% suffer mild to severe depressionNational Advisory Council on Aging
slide13
Seniors have the highest suicide rates of any age groupThe highest suicide rate is among single, white men aged 85 and older and they are more likely to succeed than females in the same age groupStatistics Canada, 2002; RNAO, 2003
slide14
“Our civilization’s greatest victory is that it has conquered disease. Its greatest failure is that it has not conquered fear of aging.”Jacques Seguela
healthy aging includes three components
Healthy aging includes three components:
  • Low risk of disease and disease-related disability
  • High level of mental and physical functioning
  • An active interaction with life
    • Maintaining close relationships with others
    • Continuing involvement in activities that have personal meaning and purpose

Gall & Swabo, Psychosocial Aspects of Aging

slide17
“All persons confront age-specific issues and obstacles that must be surmounted if they are to successfully cope with various life stages.”Gall & Swabo, Psychosocial Aspects of Aging
slide18
“Older Canadians are living longer and with fewer disabilities than the generations before them. At the same time, the majority of seniors have at least one chronic disease or condition. . . If [healthy aging is] left unaddressed, the aging of the population will have far-reaching social, economic and political impacts … that will far outweigh the cost of investing in healthy aging now.” Healthy Aging in Canada, p. vi
slide19
“Older adults can live longer, healthier lives by staying socially connected, increasing their levels of physical activity, eating in a healthy way, taking steps to minimize their risks for falls and refraining from smoking. But there are real environmental, systemic and social barriers to adopting these healthy behaviours. Some relate to inequities as a result of gender culture, ability, income, geography, ageism and living situations.”Healthy Aging in Canada, p. vii
slide20
“Ageism - discrimination based on age, especially prejudice against older people - iscommon in all societies. Ageism occurs when people believe that enabling andpromoting healthy living among seniors is unimportant or too late to make adifference. For example, it is widely recognized that promoting activity is importantfor children and youth. There are many initiatives designed to do just that. But thereis a prevailing attitude that it is not as important to be physically active in later life - that it may be too late, that the cost is prohibitive, and that the benefits aren't as greatat this stage of life. This prejudice reflects our minimized expectations of olderadulthood and misconceptions about seniors' ongoing and futureparticipation androles in society.”Healthy Aging in Canada, p. 11
slide21
As an older adult ages, society’s assumptions and stereotypes greatly restrict the roles that are available for that person.Gall & Swabo, Psychosocial Aspects of Aging
slide22
Society’s beliefs regarding the inevitability of decline in health, functioning and mental abilities as we age are prevalent. Many older persons themselves believe aging = loss of “joie de vive”.Gall & Swabo, Psychosocial Aspects of Aging
slide23
Ageism and the discrimination it creates can increase the vulnerability of older adults. Assumptions about old age may result in symptoms of trauma being mistaken for age-related illness.HelpAge International, 2003
it is time for a new vision on healthy aging a vision that
“It is time for a new vision on healthy aging – a vision that:
  • values and supports the contributions of older people;
  • celebrates diversity, refutes ageism and reduces inequities; and
  • provides age-friendly environments and opportunities for older Canadians to make healthy choices, which will enhance their independence and quality of life.” Healthy Aging in Canada, p. vii
why is it important that seniors stay as healthy as possible
Why is it important that seniors stay as healthy as possible?
  • Some 69% of older Canadians provide one or more types of assistance to spouses, children, grandchildren, friends and neighbours
  • Older Canadians make an important contribution to the voluntary sector
  • More than 300,000 Canadians 65 or older were in the labour force in 2001 Healthy Aging in Canada, p. vi
slide26
Healthy aging can delay and minimize the severity of chronic diseases and disabilities in later life, thus saving health care costs and reducing long-term care needs
  • Not surprisingly, older people in vulnerable communities (Aboriginal, economically disadvantaged groups) have the greatest chance of aging poorly
  • Chronic diseases are responsible for 67% of total direct costs in healthcare and 60% of total indirect costs ($52 billion) as a result of early death, loss of productivity and foregone income

Healthy Aging in Canada, p. vii

what does canada s older population look like
What does Canada’s older population look like?
  • Canadian seniors are a highly diverse group
  • Men and women experience aging differently
  • There are huge differences between a 65-year-old and an 85-year-old, yet both are lumped into the same category
  • In 2001, almost 20% of the immigrant population of Canada was over 65, significantly higher than the national average
  • Although a relatively small proportion of Aboriginal Canadians are seniors, the number is expected to rise significantly by 2016

Healthy Aging in Canada, p. 2-3

what does canada s older population look like28
What does Canada’s older population look like?
  • More than 90% of seniors live independently in the community and want to remain there
  • Only 7% of those over 65 live in long term care; this number increases to 14% in the 75+ age group
  • Most seniors aged 80 or older are women, the majority of whom live alone and are poor
  • Around 1/3 of Canadian seniors live alone

Healthy Aging in Canada, p. 2-3

www.phac-aspc.gc.ca

what is healthy aging

What is Healthy Aging?

“Healthy aging is ‘a lifelong process of optimizing opportunities for improving and preserving health and physical, social and mental wellness, independence, quality of life and enhancing successful life-course transitions’ (Health Canada, 2002). This definition takes a comprehensive view of health that includes physical, mental, social and spiritual well-being.”

Healthy Aging in Canada, p. 4

“Health is seen as a positive resource … not the objective of living or the absence of disease”

Healthy Aging in Canada, p. 3

what is healthy aging30

What is Healthy Aging?

“Promoting good mental health is increasingly recognized as a priority in policy and program development for seniors. By working to increase self-efficacy, self-esteem, coping skills and social support, mental health promotion empowers people and communities to interact with their environments in ways that enhance emotional and spiritual strength. It fosters individual resilience and mutual aid. Mental health promotion also challenges discrimination against those with mental health problems and fosters respect for culture, equity, social justice and personal dignity.”

Healthy Aging in Canada, p. 3-4

social connectedness and healthy aging

Social Connectedness and Healthy Aging

“Social connectedness has a positive effect on health. People who remain actively engaged in life and connected to those around them are generally happier, in better physical and mental health, and more empowered to cope effectively with change and life transitions. Distress, isolation and social exclusion increase substantially the risk of poor health and loneliness, and may even act as predictors of death.”

Healthy Aging in Canada, p. 15

social connectedness and healthy aging32
Social Connectedness and Healthy Aging
  • Social Support
    • usually provided by family, friends, neighbours and members of supportive organizations such as a church group
    • is a critical part of staying healthy physically (i.e., others provide encouragement and support to eat regularly) and mental health-wise
    • Positively influences self-perceptions of health

Healthy Aging in Canada, p. 15

social connectedness and healthy aging33
Social Connectedness and Healthy Aging
  • Social Networks
    • Much smaller than the social networks of younger adults, as many family and friends are deceased
    • As they age, some seniors start to avoid making new social contacts, as the experience of more loss is too painful
    • Declining health, decreased mobility, physical changes and sensory loss can make it very difficult for older adults to travel to or enjoy social outings
    • Social activity is also influenced by poor accessibility to public transport, substance abuse, living in poverty, language barriers and living geographically remote areas or far away from family

Healthy Aging in Canada, p. 17

social connectedness and healthy aging34

Social Connectedness and Healthy Aging

“Studies have consistently found associations between loneliness and poor health … However, the relationship between loneliness and ill-health remains ambiguous. It is unclear whether loneliness occur as a result of poor health or if poor health is a result of loneliness”

A recent study found that older women experiencing psychological stress (anxiety, feeling worthless or hopeless) were 60% more likely to die within eight years than those with lower stress levels.

Healthy Aging in Canada, p. 19

social connectedness and healthy aging35

Social Connectedness and Healthy Aging

Although great strides have been made to reduce poverty amongst Canada’s seniors, those that remain poor are more likely to be women over the age of 80, divorced or separated, and have immigrated to Canada

On average, women have more social connections than men, but older women are more likely to feel lonely, perhaps because they often outlive their spouse by several years

Healthy Aging in Canada, p. 19-20

social connectedness and healthy aging36

Social Connectedness and Healthy Aging

Research indicates that seniors that are socially isolated and eat alone are more unlikely to have unhealthy eating habits and poor nutrition

Poor nutrition, especially inadequate intake of B vitamins, contributes to cognitive decline and dementia

Healthy Aging in Canada, p. 29

social connectedness and healthy aging37

Social Connectedness and Healthy Aging

“Living alone (for both sexes) increases the person’s vulnerability to financial difficulty, chronic health problems and loneliness. Such persons commonly are in need of financial assistance and social services, and they are at risk for premature institutionalization.”

Gall & Swabo, Psychosocial Aspects of Aging

slide38
The majority of seniors live in urban areas

About 10% of Calgarians and Edmontonians are seniors (18% of those living in Victoria) www.phac-aspc.gc.ca

slide40
Healthy aging in the senior population is seriously affected by the 3 D’s – Delirium, Dementia and DepressionYet all three are often unrecognized due to their complexity and multi-faceted natureRNAO, 2003
slide41
Lack of recognition of Delirium, Dementia and Depression impacts the quality of life, morbidity and mortality of the older client RNAO, 2003
what is delirium

What is Delirium?

Delirium involves a sudden change in behaviour, attention and/or memory

Delirium usually develops over several hours or days

Delirium is a medical emergency

what is delirium44
What is Delirium?

DSM-IV diagnosis:

  • disturbance of consciousness with a reduced ability to focus, sustain or shift attention
  • a change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established or evolving dementia
  • The disturbance evolves over a short period of time (usually hours or days) and tends to fluctuate during the course of the day
who gets delirium
Who Gets Delirium?
  • Babies and children with high temperatures
  • Adults who are very ill
  • Older adults – for a variety of reasons, they can be very susceptible to delirium

CHR

delirium prevalence
Delirium - Prevalence
  • In hospital, as many as 50-65% of older adults become delirious, for a variety of reasons
  • Certain groups are at high risk:
    • Postcardiotomy – 35%
    • Post hip fracture – 40-65%
    • Geriatric/neuropsychiatric patients – 40-60%

CHR

delirium issues
Delirium Issues
  • Commonly under-diagnosed in the elderly
  • Contributes significantly to morbidity and mortality in the geriatric age group
  • Associated with increased length of hospitalization and risk of placement
  • Often misdiagnosed as dementia

GMHCS

delirium consequences
Delirium Consequences
  • Prolonged cognitive impairment
  • Cognitively, most elderly people with delirium never return to baseline
  • The longer they are delirious, the greater the chance there will be irreversible cognitive changes

GMHCS

signs and symptoms of delirium
Signs and Symptoms of Delirium
  • Don’t make sense when they speak
  • Hallucinations and delusional thinking (dead babies, pregnant, think they’re dead, kidnapped, transported by aliens, conspiracy theory, etc.)
  • Don’t pay attention to or recognize family or friends
  • Don’t recognize everyday objects
  • Forget things they’ve recently been told
  • Forget where they are and think they are somewhere else
  • Either restless and fidgety or sleepy and unresponsive
signs and symptoms of delirium50
Signs and Symptoms of Delirium
  • Believe someone is trying to harm them
  • Imagine things, people and events that never really occurred
  • Try to get out of bed, crawling over bedrails
  • Try to pull tubing and IV lines out
  • Unable to control their bladder or bowel
  • Become either very withdrawn or may yell or scream or be physically aggressive

CHR

common medical causes of delirium in the elderly
Alcohol – intoxication, withdrawal

Cardiovascular – MI, cardiac arrhythnmia, CHF, hypertensive encephalopathy, TIA, cerebral embolism

Infarction, acute CVA

Infection – pneumonia, UTI, sepsis, cellulitis, encephalitis, meningitis

Medications – any medication can cause delirium, but in particular antihista-mines, anticholinergics, psychotropics, anticon-vulsants, sedatives, digitalis, analgesics (opiates)

Common Medical Causes of Delirium in the Elderly
common medical causes of delirium in the elderly52
Metabolic – renal, pan-creatic or liver compro-mise, anemia (silent bleed), COPD, carbon monoxide poisoning, hypo- or hyper-thyroid-ism, hypo- or hyper-glycemia, hypo- or hyper-parathyoid states, Addisonian crisis, vitamin deficiency

Physiological – epilepsy

Post-anasthesia

Primary psychiatric – manic delirium, catatonic excitement

Trauma (fracture)

Tumor

Caine & Grossman, 1992

Common Medical Causes of Delirium in the Elderly
common non medical causes of delirium in the elderly
Common Non-Medical Causes of Delirium in the Elderly
  • Dehydration
  • Decreased oxygen
  • High temperature
  • Severe pain
  • Moving an elderly person from one place to another (i.e., home to the hospital, hospital to long term care, one room to another in hospital)
  • Sensory overload/deprivation
  • Isolation
  • Use of restraints
  • Drinking grapefruit juice – interferes with how some medications work

CHR

slide55
For the delirium to clear, treatment must be aimed at the cause of the problem. If there is more than one cause for delirium, all the problems need to be treated.

CHR

slide56
Psychotropic medication is not recommended for delirium unless there is a specific issue, such as aggression, and should only be used until the delirium clears

CHR

delirium at end of life
Delirium at End of Life
  • Occurs in about 80% of cases involving terminal illness
  • But – 50% of the time, if it’s the first time they’ve had delirium, the delirium is reversible
  • Second time having a delirium, 26% reversible
  • Physician and family need to discuss whether or not diagnostic work-up and treatment is appropriate

CHR

questions to ask
Questions to ask
  • Current year, month
  • Age, birth date
  • Are they married?
  • How many children, grandchildren?
  • Names of husband, children, grandchildren
  • Where are they?
  • What time of day is it (lunchtime, evening, etc.)
  • Count backwards from 20
  • Say the months of the year in reverse order

CHR

cam confusion assessment method instrument
CAM –Confusion Assessment Method Instrument
  • Acute onset
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness
  • Disorientation
  • Memory impairment
  • Perceptual disturbances
  • Psychomotor agitation or retardation
  • Altered sleep/wake cycle

Inouye, et. al.

cam confusion assessment method instrument60
CAM –Confusion Assessment Method Instrument

To have a positive CAM result, the person must display:

Presence of acute onset and fluctuating discourse

AND

Inattention

AND EITHER

Disorganized thinking

OR

Altered level of consciousness

Inouye, et. al.

prevalence of depression
Prevalence of Depression
  • 15-27% of those over 65 living in the community have depressive symptoms
  • Only 1-3% actually diagnosed with major depression
  • Prevalence may be much higher than studies indicate, especially in long term care centres (up to 47%)
  • 46% of those with Parkinson’s disease suffer from depression
  • 60% of stroke patients develop depression
  • 45% of hospitalized medically ill elderly are depressed
  • 25% of people with Alzheimer’s are depressed

GMHCS

prevalence of depression63

Prevalence of Depression

Many seniors with undiagnosed and untreated depression are admitted to long term care, bringing their chronic depression with them

Survival rates for depressed long term residents are 10% less at six months and 15% less at one year, compared to non-depressed residents

GMHCS

slide64
10-15% of seniors in the community suffer from depressive symptoms and/or clinical depressionHealthy Aging in Canada, p. 6
depression risk factors biological
Depression Risk Factors - Biological
  • Female gender (2:1)
  • Possible genetic factors (twin studies)
  • Changes in neurotransmitter activity and metabolism with aging
  • Dysregulation – thyroid, growth hormone, circadian rhythm,
  • Overall physical and cognitive decline
  • Medical issues (pain, decreased mobility, respiratory and cardiac issues)
  • Polypharmacy (lots of meds can cause depression)

GMHCS

depression risk factors biological medical illnesses associated with depression
Depression Risk Factors – BiologicalMedical illnesses associated with depression:
  • Metabolic – uremia, hypoxia, electrolyte imbalance, dehydration, etc.
  • Endocrine – thyroid dysfunction, diabetes, hyperparathyroidism, Cushing’s, Addison’s
  • Infections – UTI, pneumonia, TB, endocarditis, encephalitis
  • Cardiovascular – CHF, MI, angina
  • Pulmonary – COPD, malignancy
  • GI – malignancy (pancreas), irritable bowel syndrome, ulcer, hepatitis
  • MSK – arthritis, osteoporosis, fractures
  • Neurological, stroke, TIA, dementia, tumors, Parkinson’s
  • Other – anemia, vitamin deficiencies, malignancy, sensory loss, substance abuse

GMHCS

depression risk factors biological medical illnesses associated with depression67

Depression Risk Factors – BiologicalMedical illnesses associated with depression:

Vitamin D deficiency is common among older adults

Vitamin D deficiency has been shown to be associated with symptoms of depression and poor cognitive performance

Wilkins, et. al., 2006

depression risk factors psychosocial
Depression Risk Factors – Psychosocial
  • Loss, loss, loss, loss – roles, financial, home environment, bereavement (family, friends, pets), independence, cognitive function, health
  • Social isolation
  • Previous history of depression
  • Cognitive distortions

GMHCS

what does depression in the elderly look like

What does depression in the elderly look like?

“Older persons with significant depression may have fewer symptoms than the number required by the

DSM-IV criteria”

Gallo & Rabins, 2005, p. 2

“Older adults who are physically ill are especially at risk for inadequate treatment of depression … depression may not be easy to recognize”

Gallo & Rabins, 2005, p. 4

what does depression in the elderly look like70
What does depression in the elderly look like?
  • Irritability
  • Anxiety or worries
  • Psychomotor changes – slowing down or agitation, complaints of having “bad nerves”
  • Sleep disturbance
  • Loss of interest in activities previously enjoyed
  • Lack of interest in personal care (dishevelled look)
  • Low energy and excessive fatigue
  • Difficulty concentrating and what may appear to be cognitive impairment (misdiagnosed as dementia)
  • Feelings of hopelessness
what does depression in the elderly look like71
What does depression in the elderly look like?
  • Weepy
  • Loss of appetite, often accompanied with weight loss
  • Fixation on somatic complaints, such as digestion, bowels, headaches, pain
  • Feelings of guilt or excessive preoccupation with regrets of the past
  • Feeling punished
  • Suicidal ideation
  • Symptoms often coincide with life changes and have an abrupt onset

GMHCS

what does depression in the elderly look like72

What does depression in the elderly look like?

Seniors will commonly deny feelings of sadness or feeling depressed

Although it is normal for a senior to think about death on a regular basis, suicidal ideation is not normal – watch for statements such as “I might as well be dead” or “what’s the use?”

Gallo & Rabins, 2005

geriatric depression scale
Geriatric Depression Scale
  • Are you basically satisfied with your life?
  • Have you dropped many of your activities and interests?
  • Do you feel that your life is empty?
  • Do you often get bored?
  • Are you in good spirits most of the time?
  • Do you feel happy most of the time?
  • Do you often feel helpless?
geriatric depression scale74
Geriatric Depression Scale
  • Do you prefer to stay at home, rather than going out and doing new things?
  • Do you feel you have more problems with memory than most?
  • Do you think it is wonderful to be alive now?
  • Do you feel full of energy?
  • Do you feel that your situation is hopeless?
  • Do you think that most people are better off than you are?
geriatric depression scale short form
Geriatric Depression Scale – Short Form
  • Are you basically satisfied with your life?
  • Do you feel that your life is empty?
  • Are you afraid that something bad is going to happen to you?
  • Do you feel happy most of the time?
cornell scale for depression in dementia
Anxiety (anxious expression, worrying)

Sadness (sad voice, fearfulness)

Lack of reactivity to pleasant events

Irritability (easily annoyed, short tempered)

Agitation (restlessness, hand wringing, hair pulling)

Slowed movements, speech or reactions

Multiple physical complaints

Loss of interest, less involved in usual activities

Cornell Scale for Depression in Dementia
cornell scale for depression in dementia77
Appetite loss, eating less than usual

Weight loss

Lack of energy, fatigues easily, unable to sustain activities

Sleep difficulties – falling asleep later, multiple awakenings, early morning awakening

Mood is worse in the morning

Feels life is not worth living, death wishes or suicide attempts

Poor self-esteem – self-blame, apologetic, feeling like a failure, “I’m so stupid”

Pessimism – anticipating the worst

Delusions of poverty, illness, loss

Cornell Scale for Depression in Dementia
questions to ask for depression
Questions to ask for Depression
  • How’s your appetite?
  • How are you sleeping – do you have trouble falling asleep or waking up during the night, do you feel rested in the morning?
  • How would you describe your mood?
  • Do you ever feel sad, anxious or depressed?
  • Do you worry about anything?
  • How’s your energy level, do you feel motivated to do the things you used to enjoy or visit with others?
  • Do you feel guilty about anything, or as if you were being punished?
  • Do you go to bed at night and wish you wouldn’t wake up in the morning?

GMHCS

stress can cause
Stress can cause:
  • Suppression of the immune system
  • Impaired decision making
  • Difficulty problem-solving
  • Hypervigilance and paranoia
  • Decreased perceptual and motor skills

Gall & Swabo, Psychosocial Aspects of Aging

a major sources of stress for seniors as they age involves loss such as loss of
A major sources of stress for seniors as they age involves loss, such as loss of:
  • Family, friends and pets through death
  • Social network due to sensory loss and/or mobility issues
  • Primary control over decision-making regarding health, mobility, living situation and finances
  • Occupational and/or role status
  • Income
  • Physical and sensory functioning
  • Home and sense of belonging

Gall & Swabo, Psychosocial Aspects of Aging

memory problems can be due to
Memory problems can be due to:
  • Illness
  • Dehydration
  • Poor diet
  • Lack of sleep
  • Medications
  • Depression
  • Thyroid problems
  • Vitamin deficiencies
  • Alcohol and drug abuse
  • Many other causes – most of which are treatable
but don t panic poor memory may simply be due to
But don’t panic – poor memory may simply be due to:
  • Lack of focus (not paying attention)
  • Trying to rush
  • Being disorganized
  • Being anxious
seven problems with memory
Seven problems with memory

1. Transience

  • “Use it or lose it”
  • Memories from the distant past fades with time
  • Happens to most of us
seven problems with memory87
Seven problems with memory

2. Absent-mindedness

  • “Where are my flippin’ keys?”
  • “What was I just about to do?”
  • This is an attention problem, rather than a memory problem – related to lack of attention and superficial processing of information
seven problems with memory88
Seven problems with memory

3. Blocking

  • Can’t remember a name or particular word, but know “it’s on the tip of my tongue!”
  • Temporarily can’t access the information
  • More common as we grow older
  • Usually nothing to worry about
seven problems with memory89
Seven problems with memory

4. Misattribution

  • The memory is present, but we attribute it to the wrong thing, person, place, etc.
  • We remember the general picture of what happened, but fill in the details
  • “I remember the night we met – you wore a red dress and had your hair cut short”

“No I didn’t – I had long hair and wore a green dress!”

  • Confabulation – the “time” and “source” tags fall off the memories, so you’re not making things up, just misattributing them
seven problems with memory90
Seven problems with memory

5. Suggestibility

  • We incorporate information from other people into our memories
  • “Remember I told you” ruse – someone insists they told you something, you assume you forgot what they said and end up taking the blame - “I guess I forgot”
  • More common with age
seven problems with memory91
Seven problems with memory

6. Bias

  • Pre-existing knowledge/beliefs/feelings influence our recall
  • See a group of teenage boys walking down the street and assume they’re up to no good - “I remember they had an angry looks on their faces and I just knew they were going to do something”
seven problems with memory92
Seven problems with memory

7. Persistence

  • Can’t forget
  • Chronic fears, PTSD
  • “I remember every little detail of what happened as if it was yesterday”
  • Memory works better, we remember more detail, when we’re scared
  • Emotional arousal makes for stronger recall
  • “Natural selection” – we gain an evolutionary advantage by remembering the things that scare us
how to improve your memory
How to improve your memory
  • Pay attention!
  • Write it down
  • Repeat it out loud
  • Have a set spot in your home (by the door) for items such as keys
  • Use word association to help remember facts
how do you know if memory issues are becoming a problem
How do you know if memory issues are becoming a problem?
  • They’re noticeable to others
  • They make it difficult for someone to manage their daily activities
  • They come on after a serious illness (stroke, head injury, heart attack), etc.
remember

Remember

Significant memory loss is not an inevitable result of aging. In fact, the brain is capable of producing new brain cells and learning new things at any age.

recent research indicates the brain is like any other muscle in the body use it or lose it
Recent research indicates the brain is like any other muscle in the body: use it or lose it
  • Both mental stimulation and physical exercise are necessary to keep your mind fit as you age
  • The more the brain is involved in new learning, the better it works to gain, process and retain information
  • Seniors who walk regularly have less chance of cognitive decline, especially executive functioning (planning, organizing and the ability to juggle more than one task at once)
  • Runners can look forward to having better long-term memory

Alive Magazine, 2007

to keep the brain fit the key principles are
To keep the brain fit, the key principles are:
  • Novelty
  • Variety
  • Constant challenge
  • Some of the best ways to keep fit are reading, doing puzzles, playing cards or board games, playing a musical instrument or painting

Alive Magazine, 2007

harvard medical school s 12 tips for keeping the brain and memory healthy
Harvard Medical School’s 12 tips for keeping the brain (and memory) healthy
  • Get mental stimulation
  • Get physical exercise
  • Improve your diet
  • Improve your blood pressure
  • Improve your blood sugar levels
  • Improve your cholesterol
  • Consider taking a low dose of aspirin daily

Harvard Men’s Health Watch, 2006

harvard medical school s 12 tips for keeping the brain and memory healthy99
Harvard Medical School’s 12 tips for keeping the brain (and memory) healthy
  • Avoid tobacco
  • Don’t abuse alcohol
  • Maintain good mental health
  • Protect your head
  • Build social networks

Harvard Men’s Health Watch, 2006

dementia

Dementia

It is estimated that 750,000 Canadians will have dementia by 2031

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“Some people, no matter how old they get, never lose their beauty – they merely move it from their faces into their hearts” Martin Buxbaum
dementia definition
Dementia - Definition
  • An acquired impairment in intellectual functioning in at least two spheres:
    • Language
    • Visuospacial
    • Memory
    • Executive function
    • Ability to do routine tasks, recognition
    • Abstraction, calculation
  • Symptoms usually progress slowly and/or are relatively stable over a few years, unlike delirium

Richardson, 1995

prevalence of dementia
Prevalence of Dementia
  • 5% of those aged 65
  • Prevalence increases significantly with age
  • By age 85, about 35% of individuals suffer from dementia
  • By age 95, the prevalence is about 45%

GMHCS

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Prevalence of Dementia

Today, one out of every 20 Canadians over the age of 65 has Alzheimer’s disease.Over the age of 85, the chances of having Alzheimer’s increases to one in four. Alzheimer Society of Canada, 2006

types of dementia
Types of Dementia
  • Alzheimer’s disease
    • up until recently, thought to be the most common type - 45-50%
    • Insidious onset, progressive deterioration
  • Vascular dementia
    • pure vascular quite rare – 5-10%
    • Often a step-wise progression related to CVA’s or TIA’s
    • Often positive neuroimaging findings
    • Treatable risk factors
  • Mixed (Alzheimer’s and vascular dementias)
    • now recognized as being the most common form of dementia – 50-60%

GMHCS

types of dementia106
Types of Dementia
  • Dementia with Lewy bodies
    • 5-15% prevalence, likely underdiagnosed
    • Memory problems may not be an early feature
    • Must have two of the following early in the course of the disease: Parkinson’s features, fluctuation cognition, psychotic features (usually hallucinations)

GMHCS

types of dementia107
Types of Dementia
  • Pick’s disease/frontotemporal dementia
    • 5-10% prevalence
    • Onset often before the age of 65
    • Usually only mild memory loss
    • Progressive behavioural change
    • Early loss of social judgement and empathy
    • Impulsivity
    • Loss of insight early in course
    • Language problems may be prominent early and predate the dementia

GMHCS

types of dementia108
Types of Dementia
  • Other – 5% (i.e., Parkinson’s disease, alcohol-induced, normal pressure hydrocephalus, MS, HIV-related dementia, Creutzfeldt Jakob disease, thyroid disease)
  • Less than 5% are reversible

GMHCS

diagnosing alzheimer s disease and other dementias
Diagnosing Alzheimer’s disease and other dementias
  • Postmortem examination of the brain to detect plaques and tangles is the only way to identify Alzheimer’s disease with certainty
  • A number of psychological and memory tests have been developed which quite accurately (90-95%) allow a diagnosis of Alzheimer’s disease (or other dementia) to be made
  • Psychological and memory testing, medical examination and gathering of collateral information helps to identify the appropriate dementia(s)
  • CAT scans and brain imaging techniques such as Magnetic Resonance Imaging (MRI) are used to more accurately identify what type of changes occur in the brain
  • Genetic testing for the “Alzheimer’s gene” is now available, but not widely undertaken in Canada at present

- Alzheimer’s Society of Canada, 2006

brain changes that occur with alzheimer s disease
Brain Changes that Occur with Alzheimer’s Disease
  • Plaques and tangles develop in the brain, in a sense choking the cells of the brain to death. Messages in the brain cannot get past the damaged cells and therefore cannot get from one part of the brain to another (i.e., the back muscles send a message to the brain that they are in pain, but the message cannot get through to the part of the brain that deciphers the message, so the person is unable to identify they are in pain; rather, they become agitated “for no apparent cause” and will even say “no” if asked if they do have pain.)
  • Inflammation of the brain – the body’s normal response to trauma is to defend itself by intensifying an immune response, unfortunately escalating the death of brain cells
  • Shrinkage and degeneration of nerve cells – originates in the part of the brain responsible for thinking and memory and eventually spreads to all parts of the brain

- Alzheimer’s Society of Canada, 2006

alzheimer s disease early stage
Alzheimer’s Disease - Early Stage
  • Memory loss
  • Time and spatial disorientation
  • Poor judgement
  • Personality changes
  • Withdrawal or depression
  • Perceptual disturbances

GMHCS

alzheimer s disease mid stage
Alzheimer’s Disease – Mid-Stage
  • Recent and remote memory worsens
  • Increased aphasia (slowed speech and understanding)
  • Hyperorality
  • Apraxia (decreased ability to make the moves to do routine tasks such as brushing teeth)
  • Disorientation to time and place
  • Restlessness or pacing
  • Perseveration
  • Irritability
  • Loss of impulse control

GMHCS

alzheimer s disease late stage
Alzheimer’s Disease – Late Stage
  • Incontinence of bladder and bowel
  • Loss of motor skills, rigidity
  • Decreased appetite and dysphagia
  • Agnosia (inability to recognize and identify objects)
  • Apraxia (can’t find the right words)
  • Communication severely impaired
  • May not recognize family members or self in mirror
  • Loss of most or all self-care abilities
  • Cognition severely impaired
  • Immune system depressed

GMHCS

dementia what to watch for
Dementia – What to Watch For
  • Confabulation - making up the story or details as they go along
  • Minimizing and denying losses
  • Rambling speech
  • Perseveration - changing the subject continually to something in particular
  • Difficulty with nouns
  • Difficulty with abstract word finding
  • Generally normal mood – can be “pleasantly confused” or can become irritable when asked too many questions they can’t answer
  • May be very suspicious as to why they are being asked questions
  • “Mind your own business!”, “I’m not going to tell you”
  • “Yes, I know my age, but I’m not going to tell you”

GMHCS

risk factors for alzheimer s disease
Risk Factors for Alzheimer’s Disease
  • Age – with age comes a decline in the body’s ability to repair any damage. This decline occurs at different rates in different people.
  • Genetic risk factors – everyone has two sets of genes, one from each parent. If a person gets one “Alzheimer’s gene”, they are three times more likely to develop Alzheimer’s. If they carry both A. genes, they are ten times more likely to develop Alzheimer’s.

- Alzheimer’s Society of Canada, 2006

risk factors for alzheimer s disease119
Risk Factors for Alzheimer’s Disease
  • Diabetes – likely due to the blood vessel and heart disorders, and sometimes obesity, that accompany Type II diabetes. Also, glucose utilization is impaired in the Alzheimer brain.

Current research is looking at new anti-diabetic drugs used by those with Type II diabetes to help their bodies respond to insulin, to see if they could also be helpful in reducing the malfunctioning of the brain in those people with Alzheimer’s disease who do not have diabetes. There are encouraging indications that memory and cognition could be enhanced.

- Alzheimer’s Society of Canada, 2006

risk factors for alzheimer s disease120
Mild cognitive impairment

Being female – twice as many women than men get Alzheimer’s (live longer, more prone to diabetes and decline in estrogen post-menopause)

Down’s syndrome (almost all who live into their 40’s will develop Alzheimer’s)

Chronic inflammatory conditions

History of clinical depression

Head injury

High cholesterol levels

Strokes or “ministrokes”

High blood pressure

Stress

Lack of physical exercise

Inadequate exercising of the brain

Unhealthy eating habits

Obesity

Low level of formal education

Low socio-economic status (these last two may be indicative of other risk factors in their environment that have not yet been identified)

- Alzheimer’s Society of Canada, 2006

Risk Factors for Alzheimer’s Disease
the good news

The Good News

Research indicates that adopting a healthy lifestyle is the best way to lower the chances of developing Alzheimer’s.

Studies of identical twins have shown that around 60% of the overall risk of developing Alzheimer’s disease comes from lifestyle, rather than genetic susceptibility.

- Alzheimer’s Society of Canada, 2006

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Recent research indicates that the frequent consumption of fruit and vegetable juices may significantly reduce the risk of Alzheimer’s disease
  • Seniors who consumed three or more glasses of fruit or vegetable juice per week were 76% less likely to develop Alzheimer’s disease than those who drank less than one glass per week
  • Scientists believe that antioxidants, found in high concentration in the skin and peel of fruits and vegetables, may act to protect the brain from other chemicals that can cause damage
  • Another study showed that drinking two glasses of apple juice per day improves memory and prevents cognitive decline
  • Vitamins and minerals protect blood vessels from deterioration, ensuring optimal blood flow to the brain (Alzheimer’s has been linked to poor blood flow)

- www.alive.com, Oct/07 issue of Alive Magazine

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Why is it so important to get accurate diagnosis of dementia as soon as someone exhibits possible signs and symptoms?

The sooner someone is diagnosed, the sooner treatment can begin ↓The sooner treatment can begin, the greater the likelihood that cognitive and

memory decline can be slowed

Also, accurate diagnosis means that the most appropriate

treatment plan can be developed

Early diagnosis and treatment = ↑ quality of life

treatment of alzheimer s dementia
Treatment of Alzheimer’s Dementia
  • Aricept™ (donezipel) (cholinesterase inhibitor)
  • Exelon™ (rivastigmine) (cholinesterase inhibitor)
  • Reminyl™ (galantamine) (cholinesterase inhibitor)
  • Ebixa® (memantine hydrochloride)
  • Basically, these medications help messages to be conveyed from one nerve cell to the next, so that messages have a better chance of getting through to the right place
is it depression or dementia
Is it depression or dementia?
  • Common disorders in the elderly
  • They may co-exist
    • Alzheimer’s disease – up to 25% experience depression
    • Vascular dementia – an even higher prevalence of depression than AD
  • Many symptoms overlap, making them difficult to distinguish
  • Depression may cause reversible dementia

GMHCS

is it depression or dementia common symptoms
Is It Depression Or Dementia – Common Symptoms
  • Eating changes
    • Dementia – usually gradual weight loss over years, but may be a large weight increase due to inactivity, hyperorality (frontotemporal dementia), medications, etc.
    • Depression – subacute changes over weeks to months, weight may increase or decrease

GMHCS

is it depression or dementia common symptoms128
Is It Depression Or Dementia – Common Symptoms
  • Sleep disturbance
    • Dementia – gradual loss of diurnal pattern over years
    • Depression – subacute changes over weeks to months
      • Often middle night awakening or early morning awakening
      • May be excessive sleep

GMHCS

is it depression or dementia common symptoms129
Is It Depression Or Dementia – Common Symptoms
  • Mood
    • Dementia – may have early depressive mood; later, mood fluctuates according to circumstances
      • Irritability fairly common
    • Depression – pervasive changes over weeks, nearly every day
      • Sadness
      • Irritability
      • Loss of pleasure

GMHCS

is it depression or dementia common symptoms130
Is It Depression Or Dementia – Common Symptoms
  • Mood lability
    • Dementia – increases with time, often unrelated to circumstances (laughing or crying anappropriately)
    • Depression – more crying, congruent with sadness
  • Apathy
    • Dementia – loss of interest and initiative without sadness
    • Depression – subacute onset with sadness and feelings of helplessness

GMHCS

is it depression or dementia common symptoms131
Is It Depression Or Dementia – Common Symptoms
  • Concentration
    • Dementia – usually intact until the late stages
      • slowly progressive changes
      • Person often unaware and unconcerned
    • Depression – subacute changes
      • often a major concern for the person
      • “Do I have dementia?”
      • Many “I don’t know” answers on testing
      • Give up easily

GMHCS

is it depression or dementia132
Depression:

Depressed senior exagger-ates their disabilities: “I can’t”, “I don’t know”

Tests better than anticipated

Inability to concentrate

Insomnia, difficulty with sleep onset/early morning waking, hypersomnia

Slow, sluggish speech

Commonly have feelings of guilt, worthlessness

Ruminations common

Suicidal ideation much more common

Dementia:

Senior with dementia confabulates, minimizes and denies losses

Rambling speech, difficulty with nouns

Difficulty with abstract word finding

Generally normal mood

Sleep is fragmented, often awakens at night

GMHCS

Is it depression or dementia?
is it depression or delirium

Is it depression or delirium?

Symptoms of depression may occur in delirium, but depression cannot be diagnosed until the delirium has cleared

One study showed that 42% of elderly people sent to a psychiatric service for treatment of depressive symptoms actually had delirium

GMHCS

what to look for notice
Appearance

body frame

Size

personal hygiene

Dress

Psychomotor behaviour

Speech

Affect

Mood

Eye contact

Thought content

Perceptual disturbances

Person’s description/percep-tion of the problem

Cognitive state (MMSE)

GMHCS

What to Look for/Notice
mmse mental status exam
MMSE (Mental Status Exam)
  • Needs to be administered and scored properly
  • When done on a regular basis, can indicate progression of dementia
  • If there is a drastic change in a short period of time and the person has not had a CVA, poor score can indicate delirium

GMHCS

mmse mental status exam137
MMSE (Mental Status Exam)
  • Orientation: what is the year, season, month, date, day of week, country, province, city, name of building, room number
  • Registration/attention & short-term memory: remember three words, spell “world” backwards
  • Language/spatial orientation & coordination: name a pen and watch, repeat phrase, read a sentence, write a sentence, copy a design, 3-part instruction

Molloy, 1989

moca montreal cognitive assessment
MoCA (Montreal Cognitive Assessment)
  • Better assessment tool for mild dementia or dementias such as frontotemporal, where confusion and poor memory are not an issue
  • Picks up more subtle changes in cognition
  • May score 30/30 on the MMSE, yet score poorly on the MoCA

GMHCS

sensory loss
Sensory Loss
  • Gradual sensory loss is a “normal” part of aging
  • Loss of vision, hearing, taste, smell and touch can adversely affect a senior’s quality of life

Orzech, Social Work Today

sensory loss141
Sensory Loss
  • Smell and taste play a key role in food enjoyment and trigger feelings of hunger
  • Loss of smell and taste, and therefore motivation to eat a variety of foods, contributes to poor nutrition in the elderly
  • As a result of sensory loss, many seniors add more salt and sugar to their food in order to try to make the food taste better

Orzech, Social Work Today

sensory loss142
Sensory Loss
  • Macular degeneration is the most common age-related vision disorder affecting seniors. People with macular degeneration are unable to see things in the centre of their vision field
  • Diabetic retinopaty (blurry and fluctuating vision) affects the sight of many seniors
  • Poor vision often leads to social isolation and boredom, as it becomes impossible to read or perform usual tasks

Orzech, Social Work Today

sensory loss143
Sensory Loss
  • More than 25% of seniors over the age of 75 report problems with their eyesight, even when wearing glasses
  • Poor vision often leads to social isolation and boredom, as it becomes impossible to read or perform usual tasks

Orzech, Social Work Today

sensory loss144
Sensory Loss
  • Around 30% of seniors have significant hearing loss
  • As with poor vision, hearing loss can result in social isolation and boredom, as communication with others, in person or over the telephone, is so difficult
  • Some studies show a relationship between hearing loss and depression, although not as strong a connection as with vision loss

Orzech, Social Work Today

sensory loss145

Sensory Loss

Many of those in the helping professions, including social workers, are unaware of the problems faced by seniors as a result of sensory loss.

Social workers need to pay attention when a client has a precursor such as diabetes so that appropriate resource information can be provided to the client.Orzech, Social Work Today

sensory loss146

Sensory Loss

“Nor are many social workers aware of the connection between vision loss in older adults and depression. Older people with vision impairment are anywhere from two to five times more likely to suffer from depression than someone without vision impairment. Between ¼ and 1/3 of visually impaired elders report a significant number of depressive symptoms.”Orzech, Social Work Today, p. 21

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Pain
  • Pain issues are reported by 25-50% of seniors living in the community and 45-80% of long-term care residents
  • Diagnosis of pain in the frail elderly can be complicated by cognitive impairment due to delirium or dementia, cultural barriers, vision and hearing loss, and inaccurate beliefs (“pain is an inevitable part of aging”)

Feldt, 2005

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Pain
  • Diagnosis in cognitively-impaired adults is further complicated by the fact that when they are sitting quietly, they may forget they have pain and appear to be “just fine”
  • Seniors with cognitive impairment (dementia or delirium) are often unable to recognize or describe their discomfort – in other words, they are unable to recognize their discomposure as pain and, therefore, may deny having pain or discomfort if asked, or they may describe their discomfort as “I hurt all over”

Feldt, 2005

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Pain
  • Studies have shown that, with cognitively impaired seniors, aggression, agitation or resistance to care can be related to untreated or poorly managed pain issues
  • New behaviours such as aggression or agitation in seniors with dementia may indication an underlying infection or other medical imbalance which is causing discomfort (i.e., urinary tract infection, constipation, cardiac changes or prolonged discomfort from a fracture)

Feldt, 2005

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Pain
  • The cognitively-impaired senior may deny discomfort and present with non-verbal symptoms such as:
    • facial movements (grimacing, frowning, raising cheeks)
    • Body movements (bracing, guarding, rubbing, touching)
    • Vocalizations (moans, groans, yelling, shouting)
    • Poor appetite
    • Sleep disturbance
    • Depressed mood
    • Agitated behaviour
    • Withdrawn
    • Weepy

Feldt, 2005

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Pain
  • If left untreated, pain issues can have serious consequences, including depression, isolation, sleep disturbance, impaired ambulation and slowed healing
  • Treatment includes treating underlying medical issues, finding the right analgesic for the type of pain and the correct dosage

Feldt, 2005

sleep issues
Sleep Issues
  • Sleep issues are a common complaint amongst seniors, yet they are rarely diagnosed or treated, even by geriatric specialists – despite the fact that sleep disorders can have harmful effects on healthy aging
  • “Sleep disturbances among the elderly are associated with significant morbidity and mortality and increase the risk for nursing home placement”

McCall, 2004, p. 9

sleep issues153
Sleep Issues
  • “Sleep disturbances in the elderly, and the subsequent disruption of caregivers’ sleep, exact a toll on family support. Insomnia has been cited as a primary factor in caregivers’ decisions to institutionalize an elder, with … 52% of admissions to long-term care directly attributable to elderly sleep disturbance.”
  • “A survey of 1855 elderly urban residents found that insomnia was the strongest predictor among males for both mortality and nursing home placement”

McCall, 2004, p. 10

sleep issues154
Sleep Issues
  • Sleep disturbance can contribute to cognitive decline and, if unrecognized, becomes another factor that can impair accurate diagnosis of dementia (i.e., person gets a diagnosis of dementia, rather than insomnia and the sleep disorder goes unrecognized and untreated)
  • Staying asleep is more of an issue with older adults than falling asleep

McCall, 2004

sleep issues155
Sleep Issues
  • There are no guidelines regarding how much sleep is appropriate for older adults
  • Even healthy seniors tend to spend more time resting in bed then younger adults, with no more time spent sleeping
  • Studies show that older adults often spend more time in light sleep and less time in deep sleep than younger adults

McCall, 2004

sleep issues156
Sleep Issues
  • Insomnia is often a “side effect” of chronic disease, poor physical health or psychosocial issues
  • Sleep disturbance in the elderly is strongly correlated with depression

McCall, 2004

common causes of sleep disturbance
Caffeine

Nicotine

Perscription drugs (beta blockers, decongestants, thyroid medications, corticosteroids, antidepressants, chemotherapy, benzodiazepenes

Sleep disorders (sleep apnea, periodic limb movement disorder, nocturnal myoclonus, restless legs syndrome, circadian rhythm sleep disorder, rapid eye movement behavioural disorder)

Common Causes of Sleep Disturbance
common causes of sleep disturbance158
Pain

Neurological disease (Parkinson’s, Alzheimer’s)

Chronic medical illness (arthritis, cardiovascular disease, gastrointestinal disease, asthma, COPD)

Thyrotoxicosis

Daytime napping

Depression

Anxiety

Life stressors

Bedtime worrying

Mania or hypomania

Environmental causes

Noise

Eating or exercise before bedtime

Common Causes of Sleep Disturbance
treatment of sleep disturbance

Treatment of Sleep Disturbance

Studies have shown that the use of sleep medications could be reduced by 74% if non-pharmacological sleep protocols are used on a regular basis, such as:

back rubs

warm drink

relaxation tapes, etc.

CHR

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Case #1:A 78-year-old widow presents with insomnia. Her medical history includes hypertension, diabetes, possible Crohn’s disease, recurrent urinary tract infections, cataracts and bilateral knee replacement surgery a number of years ago. She denies any psychiatric history.Mrs. Smith lives alone in her own home. For the past five years, she has cared for her ailing husband, until his death one month ago. She admits that looking after him was a strain and, at times, she “could hardly stand it”. Since her husband’s death, she has stopped going to church and no longer socializes with friends. She is alert and oriented, but appears to be stressed. Her MMSE score is 25/30; she lost points on orientation and concentration. She denies feeling depressed, but scored 15/30 on the Geriatric Depression Scale.Gall, Clinical Geriatrics
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Case #2:Mr. Johnson is a 90-year old gentleman who lives at home with his wife. Mrs. Johnson has had health problems for many years and he has been her main caregiver.Mr. Johnson was admitted to hospital for further investigations following a fall. While in hospital, he was confused, resistive to care, rambling incoherently and did not recognize family members. Family were reassured that this was his “dementia”. Family were perplexed, as they had not noticed much confusion or serious cognitive impairment prior to his hospitalization. They were reassured that he had probably been “covering up” his deficits for some time. Family were told that Mr. Johnson was not safe to look after his wife. Therefore, the decision was made for long term care.
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Case #3:An 82-year-old widow presents with memory problems and symptoms consistent with major depressive disorder. She is having difficulties with independent functioning, so admission to hospital is arranged for further work-up and treatment. Her medical issues include arthritis, hypothyroidism, glaucoma and NIDDM. Two months ago, she had a fall, resulting in a compression fracture, so Tylenol #3 is started for pain. Other medications include Synthroid, multivitamin and Pilocarpine eye drops. To treat the depressive features, an anti-depressant is also started. Not long after admission, she begins to complain of hearing music. Confusion and distress is evident – she claims she is about to give birth, blood is everywhere, the head is crowning. She appears to be restless and is awake throughout the night. GMHCS
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Case #4:Mr. Jones is an 87-year-old gentleman with mild dementia. He had been through a difficult period of adjustment since his admission to the nursing home several months earlier. He wa critical of staff, impatient with his roommate and plagued by insomnia.One night at 3:00 am, he woke up, put his clothes on over his pajamas and went to the dining room for breakfast. When staff tried to orient him, he exploded in anger and accused them of trying to make him look like a fool. He refused to go back to bed and paced the halls until morning. Staff who changed his sheets noticed that, for the first time since admission, he had been incontinent of urine.On reviewing his chart, it was noted he had been started on Oxazepam for insomnia 5 days earlier. He was not cooperative with a physical exam and refused to answer mental status questions, complaining bitterly that this was an infringement of his rights.The oxazepam was discontinued. Two weeks later, however, Mr. Jones had deteriorated further. He appeared disheveled, swore at staff and shook his fist at them whenever they tried to approach him. During the afternoon he slept for hours and was difficult to rouse. He started complaining of bugs in his room. GMHCS
it is extremely important to obtain an accurate picture
It is extremely important to obtain an accurate picture
  • You need to get an accurate sense of what this senior was like before you met them so that you can determine whether there has been a sudden change
  • While respecting privacy and confidentiality issues:
    • gather collateral information from as many sources as possible (i.e., medical history – do they have a history of delirium, depression, UTI’s, etc.)
    • Talk to different sources - the client, family members, supports in the community, etc.
    • If possible, visit their home to get a better idea of what their day-to-day functioning is like
it is extremely important to obtain an accurate picture168
It is extremely important to obtain an accurate picture
  • Be aware of the potential for adverse cognitive effects/change in behaviour from many medications, infection, other medical imbalance, pain, constipation, poor nutrition, etc.
  • Consider the signs and symptoms you are seeing in context with the senior’s history
  • Don’t jump to conclusions!
create opportunities for honest sincere dialogue

Create opportunities for honest, sincere dialogue

Ask appropriate questions

Be aware of your biases and society’s biases

create opportunities for honest sincere dialogue170

Create opportunities for honest, sincere dialogue

Ask appropriate questions

Be aware of your biases and society’s biases

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Most seniors – and their families – don’t know where to go for help, who to talk to or how to ask for help

They’re from a generation that never asked for help for anything

They’re also ashamed to admit they have a “problem”

assess the capabilities of their existing support system

Assess the capabilities of their existing support system

Refer to an appropriate professional for more thorough assessment, supportive counselling, etc.

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Social workers can provide appropriate and accurate information to seniors and their family so they can make informed choices

Provide opportunities to discuss the benefits and risks of choices

you may encounter situations where a senior obviously needs help yet refuses any type of support

You may encounter situations where a senior obviously needs help, yet refuses any type of support

In such a situation, risk of harm (to self and others) needs to be properly assessed.

It may be necessary to have a competency assessment done.

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If unsure what to do, discuss the case with other qualified personnelHealth regions have ethics boards and most are more than willing to discuss a case

If risk of harm to self or others is apparent, it may be necessary to complete a Form 1 to have the person committed to hospital or psychiatric service for assessment

find out what resources are available for seniors in your community
Find out what resources are available for seniors in your community
  • Local Health Authority - Seniors’ Health
  • Family physician (should know who to refer to for assessment, physician referral usually necessary for geriatric &/or psychiatric assessment)
  • Alzheimer’s Society
  • Community support agencies
  • Grief support programs
  • Competency assessment teams
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Local Health Authority - Seniors’ Health
  • Family physician (should know who to refer to for assessment, physician referral usually necessary for geriatric &/orSpecialized Geriatric Services
  • There are a number of geriatric services available. Clients seen within these services are typically frail, complex older adults who present with deterioration in their functional status. This deterioration may either be on a physical, cognitive or a mental health basis, or a combination of the three. These individuals generally have a number of underlying chronic conditions. The client’s family and support system are often included in the services offered. Components to the services include both inpatient and outpatient geriatric services.
  • Referrals to any of the following services is centralized though a One Line Referral Service. Family physicians, Home Care Coordinators and others use a common referral form to access any one of these services. Referrals are triaged by Seniors Health professional staff. General information about these services is obtained by calling 267-2991 or 943-3453.
  • Geriatric Consultation Services
  • Substance Abuse in Later Life (SAILL)
  • Mental Health Geriatric Team
  • Alzheimer and Dementia Resource Clinic  (ADRC)
  • Calgary Fall Prevention Clinic
  • Cognitive Assessment Clinic
  • Carewest Day Hospital
  • Carewest Comprehensive Community Care (C3)
  • Inpatient geriatric assessment and rehabilitation units
  • Inpatient geriatric consultation services
  • Alzheimer’s Society
  • Community support agencies
  • Grief support programs
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Mental Health & Addictions Services

Geriatric Programs & Services

Access Mental Health

Calgary Health Region at Sunridge Mall

Community Geriatric Mental Health Services

Geriatric Mental Health Acute Inpatient, Unit 48 RGH

Geriatric Mental Health Consulting Service

Geriatric Mental Health Outreach Team

Geriatric Rehabilitation & Recovery Unit

South Calgary Health Centre

Geriatric Services Educational Series

For information on any of the services listed callAccess Mental Health @ 943-1500

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Mental Health & Addictions Services

Rural Programs & Services

Access Mental Health

Airdrie Mental Health Clinic

Black Diamond Mental Health Clinic

Bow Valley Mental Health Clinic

Chestermere Mental Health Clinic

Claresholm Centre for Mental Health & Addictions

Claresholm Mental Health Clinic

Cochrane Mental Health Clinic

Didsbury Mental Health Clinic

High River Mental Health Clinic

Nanton Mental Health Clinic

Okotoks Mental Health Clinic

Shared Mental Health Care, Rural South

Strathmore Mental Health Clinic

Vulcan Mental Health Clinic

Rural South Community Mental Health Workshops

For information on any services listed call Access Mental Health @ 943-1500

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Especially for Seniors

Programs & Services

Capital Health has published a guide listing the programs and services it provides for seniors. For a copy of this pdf click here

As well, we've gathered resources and links relating to the health information needs of seniors and their caregivers. Use the topic links below to browse for health information that interests you. Or find out about programs and services of interest to seniors by using the link to the right.

Information is available on topics such as keeping fit, eating to stay healthy, and living safely at home. Additionally, there is information about some disorders and conditions that you might have questions about.

Community Care Services provides an integrated system of health and personal support services to clients based on assessed need. Our services are provided in clients' homes, and through a variety of supportive living environments and continuing care facilities.

Community Care Access

The first point of contact is to call Community Care Access (known formerly as Information and Intake) at 496-1300. Community Care Access provides telephone screening and needs assessment 24 hours a day, seven days a week.

ensure you re part of the solution not part of the problem
Ensure you’re part of the solution, not part of the problem:
  • Deal with any issues presented by a senior, rather than ignoring them
  • Be aware that seniors often feel disenfranchised, ignored and of little value in today’s society
  • Talk about seniors and their plight whenever possible, in order to battle society’s general lack of awareness, lack of understanding, apathy, ambivalence and tendency to “put blinders on” whenever the issues of the elderly are mentioned
remember182

Remember:

The elderly, like all other human beings, deserve the opportunity to live as comfortably and contentedly as possible

They also have the right to take risks

Even those seniors with advanced dementia can have their quality of life improved by proper care and attention

Unlike younger adults, seniors are much more likely to need your help to ensure their needs are met

therapies etc
Therapies, etc.
  • Reminiscence therapy
  • Cognitive behavioural
  • Motivational interviewing
  • Solution-focused
bibliography
Bibliography
  • Alexopoulos, G.B., et. al., Cornell Scare for Depression in Dementia, Biological Psychiatry, Vol. 23, 1988, pp. 271-284
  • Brink, T.L., et. al., Screening Test for Geriatric Depression, Clinical

Gerontologist, Vol. 1, No. 1, 1982, pp. 37-43

  • Caine & Grossman, Neuropsychiatric Assessment, in Birren, Sloane &

Cohen, eds., Handbook of Mental Health and Aging, 1992

  • Gallo, J.J., et. al., Handbook of Geriatric Assessment, Gaithersburg, MD: Aspecn Publications, 1995
  • Inouye, S.K., et. al., Clarifying Confusion: The Confusion Assessment Method – a

New Method for Detection of Delirium, Annual of Internal Medicine, Vol.

113, pp. 941-948

  • McCall, W.V., Sleep Disturbance in the Elderly: Burden, Diagnosis, and

Treatment, Primary Care Companion, Journal of Clinical Psychiatry,

Vol. 6, No. 1, 2004, pp. 9-20.

  • Molloy, W., Standardized Mini Mental State Examination, Ontario: New Grange Press, 1989
  • Orzech, D., Sensory Loss in Aging, Social Work Today, Vol. 7, No. 1, p. 20
bibliography185
Bibliography
  • www.aafp.org

American Academy of Family Physicians

Gallo, J.J. & Rabins, P.V., Depression Without Sadness:

Alternative Presentations of Depression in Late Life,

American Family Physician, September 1999

  • www. ajgponline.org

American Journal of Geriatric Psychiatry

wilkins, C.H., et. al., Vitamin D Deficiency is Associated

with Low Mood and Worse Cognitive Performance in Older

Adults, Vol. 14, December 2006, pp. 1032-1040

  • www.alive.com Alive Magazine (October 2007)
  • www.alzheimer.ca Alzheimer’s Society of Canada A Report on Alzheimer’s Disease and Current Research (2006)
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Bibliography
  • www.calgaryhealthregion.ca

Calgary Health Region website

Mental Status Exam – learning module

  • www.clinicalgeriatrics.com Clinical Geriatric Journal Gall, J.S. & Szwabo, P., Psychosocial Aspects of Aging
  • www.health.harvard.edu Harvard Medical School

Harvard Men’s Health Watch, Vol. 10, No. 10 (May 2006)

  • www.mocatest.org

Montreal Cognitive Assessment Tool (MoCA)

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Bibliography
  • www.phac-aspc.gc.ca Public Health Agency of Canada, Aging and Seniors Statistics re seniors Healthy Aging in Canada: A New Vision, A Vital

Investment, From Evidence to Action – A Background Paper

Prepared for the Federal, Provincial and Territorial

Committee of Officials (Seniors)

  • www.rehabilitation-director.advanceweb.com

Advance Online Editions for Directors in Rehabilitation

Feldt, K.S., Pain in the Elderly, Issue date 10/3/2005

  • www.rnao.org Registered Nurses Association of Ontario

Screening for Delirium, Dementia and Depression in Older

Adults, Nursing Best Practice Guidelines, November 2003

Caregiving Strategies for Older Adults with Delirium,

Dementia and Depression in Older Adults, Nursing Best

Practice Guidelines, November 2003

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