1. Interventions for Geriatrics in
Mental Health
By: Amber Knight, Sibyl Kirkland,
and Heather Zimmerman

2. Geriatrics
• Population in United States 2012
– US residents age 65 and over: 41.4 million
• Life expectancy
– Men at 65 years: 17.7 years/Women at 65 years:20.3 years
• Heath Status
– Non-institutionalized persons age 65 and over in fair or
poor health: 24.7%
– Non-institutionalized s age 65 who needs help with
personal care from others: 7.3%
(CDC, 2012)

3. Geriatrics
• Aging is not associated with significant
cognitive decline, but minor memory problems
can occur a normal part of aging.
(Sadock & Sadock, 2008).

4. Neurocognitive Disorders
• DSM – 5 defines the cognitive domains which
identifies the criteria of the disorders , their levels
and the subtypes to diagnosis.
• Five domains includes:
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Complex attention
Executive function
Learning and memory
Language
Perceptual –motor
Social cognition
(American Psychiatric Association, 2013)

5. Neurocognitive Disorders
• Delirium
• Major & Mild Neurocognitive disorders
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–
–
–
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Alzheimer’s disease
Frontotemporal lobar degeneration
Lewy body disease
Vascular disease
Traumatic brain injury
Substance/medication use
HIV Infection
Prion disease
Parkinson’s disease
Huntington’s disease
(American Psychiatric Association, 2013)

6. Dementia
• Not a specific disorder but an universal term to describe the vast
range of symptoms
• Defined as an acquired, persistent , and progressive impairment in
multiple cognition leading to significant functional decline.
• 1 of 3 US residents 55 years of age and older & 1 of 5 at least 65
years of age by the year 2030.
• Dementia prevalence increases with age
– 5 % in 71 to 79 years of age
– 37.4 % in 90 years of age and greater
• “Elderly patients with dementia and other psychiatric disorders are
most often cared for by their primary care.”
(McCarron, Xiong, & Bourgeois, 2009)

7. Treatment
• Early diagnosis and treatment of dementia is
important to slow cognitive and functional
decline.
(McCarron, Xiong, & Bourgeois, 2009)

8. Delirium
• Defined as an acute decline in attention and
cognition , is a common, life-threatening and
potentially preventable clinical syndrome in
older adults.
(Ramaswamy et al, 2010)

9. Characteristics
• Rapid onset
• Most common psychiatric syndrome in general
medical setting and associated with significant
mortality and morbidity both during and post
hospitalization Results from urinary and upper
respiratory infections, dehydration, and medicationrelated mishaps
• Preventable and treatable
• Not always transient and reversible
(Tusaie & Fitzpatrick, 2013)
(Ramaswamy, et al., 2010)

10. Additional Characteristics
• Up to 2/3 of all cases of delirium in the elderly
increases the risk for dementia.
• More than 20% of hospitalized patients aged
65 years and older each year increases
hospital costs by $2,500 per hospital stays.
• Admission ranges 14% to 24% whereas
incidence during hospitalization can be as high
56%.
(Ramaswany et al, 2010)

11. Assessment Tool
• Delirium Observation Screening Scale
• CAM- Confusion Assessment Tool
• CAM - ICU
• Other tools: MDAS, ICDSC, Cognitive
Test for delirium; DSI
(Tusaie & Fitzpatrick, 2013)

12. Treatment
• Non pharmacological strategies first
line of treatment
• Reorientation and behavioral
intervention
• Clear instructions with frequent eye
contact with patients
• Minimized sensory impairments in
vision and hearing loss by providing
the assist tools.
• Avoid physical restraint ( decreases
mobility, increased agitation,
prolongs delirium
• Limited room and staff changes
provide a quiet setting with low level
lightning at night. (Ramaswamy, et al.,
2010)
• Pharmacological
• Haloperidol, Risperidone,
Olanzapine, Quetiapine
– widely used drugs for the treatment of
delirium-related agitation
• Lorazepam
– Reserved for treatment of drug withdrawal,
diffuse Lewy body disease
• Use of drugs for hypoactive delirium
must be warranted
– Increase sedative effects
(Ramaswamy, et al., 2010)

13. Alzheimer’s Disease
• Defined as an degenerative progressive
neuropsychiatric disorder resulting in global
impairment of cognition, emotions, and
behavior leading to physical and functional
decline and death.
(Tusaie & Fitzpatrick, 2012)

14. Characteristic
• Insidious and progressive onset
• Current estimates suggest that 1 in 8 persons
over 65 have Alzheimer’s disease and a total of
5.3 million Americans have Alzheimer’s
disease. (Alzheimer's, 2009)
• 6th leading cause of death in the United States
overall and 5th leading cause of death for those
age 65 and older. (Alzheimer's Association,
2013)

15. Impact on Caregivers.
• An estimated 11 million caregivers provide 12.5
billion hours of care each year to an estimated 5
million persons with dementia
• 15.4 million caregivers provided more than 17.5
billion hours of unpaid care valued at $216 billion.
• 40% to 70% of caregivers exhibit significant
symptoms of depression, with 25% to 50% meet the
criteria of major depressive disorder.
(Alzheimer’s Association, 2011; Hoch, 2009; Nichols, Martindale-Adams, Burns, Graney, & Zuber, 2011 as cited in
Easom, Alston, & Coleman, 2013) (Alzheimer's Association, 2013)

16. Screening Tools
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Folstein’s Mini Mental State Examination
Short, Portable Mental Status Questionnaire
Clock Draw Test
Minicog
MoCA
Functional Assessment Screening Tool
Tusaie&Fitzpatrick, 2013

17. Interventions
• Safety Assessments
• Care for Caregivers
• Psychosocial
– Cognitive rehabilitation, memory training, and
engagement in pleasurable activities
– Sensory stimulation
– Recreational activities and social interaction
– ABC behavioral model
(McCarron, Xiong, & Bourgeois, 2009)

18. Treatment
Cholinesterase Inhibitor (ChEIs)
N-methyl-D-aspartate (NMDA)
Donzepril(Aricept)
Rivastigimine ( Exelon)
Galantamine ( Razadyne)
• Memantine ( Namenda)
(McCarron, Xiong, & Bourgeois, 2009)
(McCarron, Xiong, & Bourgeois, 2009)

19. Depression
• 25% of patients with AD may experience major
depression.
• May contribute to cognitive impairments.
• Dementia, delirium and depression are not mutually
exclusive conditions all three conditions can be
present in the same individual and any given time.
• Increased risk for suicide if depression is not
detected in older adults with chronic illness and
those with new dx of dementia.
(Sadock & Sadock, 2008) (McCarron, Xiong, & Bourgeois, 2009)& (Tusaie & Fitzpatrick, 2013)

20. Depression and the Older Adult
• 15% of older adults have depressive symptoms
• Age itself is not a risk factor
• Being widowed or having a chronic illness increase
risk for depressive disorder
• Presenting symptoms in older adults may differ
from those of younger adults
• Increased emphasis on somatic complaints in older
adults

21. Co morbidity of Depression
• Co morbidity of depression with physical
disorders is common
• Negatively influences the course of the
depression
• Increases functional impairment, health
costs, and use of health services
• Common conditions associated with
depression

22. Depression and Suicide
• 20% is the suicide rate among older adults
• White males over 85 have the highest suicide
completion rates
• Males over 80 take their lives at twice the
rate of women
• Over 70% of older suicide victims had had
contact with PCP in the 3 months prior to
the suicide

23. Risk Factors for Suicide Among Older
Adults
• Medication
• Demographics
• Clinical

24. Suicide Management in Older Adults
• Promote connection with personal, family,
and community to prevent suicide
• Treatment doesn't differ from treatment in
younger adults

25. Geriatric Depression Scale
• Scales specific for adults 60+
• Available in long and short form
• Can be downloaded at:
www.stanford.edu~yesavage/Testing.htlm

26. Treatment
• Same medications are used just in lower
dosages, emphasis upon self-efficacy, activities
and social involvement in psychotherapy in the
geriatric population.
(Tusaie & Fitzpatrick, 2013)

27. Pharmacological Treatments
• Treatment basically the same as in younger
adults
• Antidepressants
• SSRIs and TCAs most common in older
adults
• Older adults are at increased risk for drug
interaction
• Lower doses of medication are needed

28. Non-Pharmacological
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•
•
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Cognitive Behavioral Therapy
Cognitive Bibliotherapy
Problem-Solving Therapy
Brief Psychodynamic Therapy
Reminiscence Therapy

29. Loss
• Loss is an "absence of an object, position,
ability, or attribute.
–Loss of someone or something that is significant to
that individual.
–Independence (precious commodity, feel value less
or useless)
–Deprivation (fewer opportunities, physical frailty,
shrinking of individual's feeling of competence and
self-esteem
(Ferrell & Coyle, 2006)(Harris, 2011)

30. Grief
• Grief is a "person's emotional response to the
event of loss"; " state of mental and physical
pain that is experienced when the loss of
significant object, person, or part of the self is
realized".
(Ferrell & Coyle, 2006)

31. Grief
• Major categories of grief
– anticipatory grief
– uncomplicated grief
– complicated grief
– disenfranchised grief
– Unresolved grief
(Ferrell & Coyle, 2006)

32. Characteristics
• Symptoms of grief
•
•
•
•
Physical
Cognitive
Emotional
Behavioral

33. Assessment
• The bereaved are often exhausted and fatigue
from caring for the love one who died and
forgo their own needs. NP’s should
– Inquire of routine physical exams, social networks,
family roles, and major changes within self.
– Be aware of clinical depression, prolonged deep
grief, self destructive behavior, increased use of
alcohol and/or drugs, preoccupation with the
deceased to the exclusion of others.
(Ferrell & Coyle, 2006)

34. Interventions
• No medications exist to treat symptoms of grief
because grief is not consider an illness.
• Use of antidepressant and sleep medications
may help with severe and complicated grief
• Support Groups
• Counseling
(Rainer, 2013, p.56)

35. Anxiety and the Older Adult
• Anxiety is a common and a major problem in
older adults
• Receives less attention then depressive
disorders
• 15.3% of adults over the age of 60 are
diagnosed with anxiety disorders
• In older adults anxiety is a risk factor for
greater disability

36. DSM Anxiety Disorders in Older Adult
• Most common
– GAD
– Phobias
• Less common
– OCD
– Panic Disorders

37. Medical Co morbidities
• Studies have shown an association between anxiety
and medical illnesses including but not limited to:
•
•
•
•
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•
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Diabetes
Dementia
Coronary heart disease
Cancer
COPD
gastrointestinal disorders
Parkinson's disease

38. Anxiety and Depression
• Anxiety in older adults often co-occurs with
depression
• 50% of older adults with depression had co morbid
anxiety
• An increased risk for poor outcomes in cases of co
morbid anxiety and depression
• Older adults with anxious depression report
increased suicidality
• Anxiety more commonly precedes depression

39. Diagnostic Difficulties
• Medical Conditions
• Dementia
• Depression

40. Geriatric Anxiety Inventory
• Specific scale for older Adults
• Sound psychometric properties specific for
older adults
• 20 item self report
• Greater then 10 “agrees” may indicate an
anxiety disorder

41. Pharmacological Treatment
• Use with caution in older adults
• Benzodiazepines
– Most common
• Antidepressants
– SSRIs
– MAOIs
– TCAs

42. Non-Pharmacological
• Evidenced-based psychological
treatments in older adults
• Relaxation Training
• Cognitive Behavioral Therapy (CBT)
• Supportive Therapy

43. Behavioral Health and the Older
Adult
• Insomnia
• Insomnia is one of the most dominant behavioral health issue that older
adults face.
• 30-60% of all older persons have one or more sleep complaint
(McCurry, 2007)
• Sleep complaints for most older adults include:
– Difficulty falling and staying asleep
– Early morning awakenings
– Excessive day time sleepiness
•
– Day time fatigue
(APA, 2005)

44. Behavioral Health cont…..
DSM-5 Insomnia Disorders
o Is defined as, “A predominant complaint of dissatisfaction
with sleep quantity or quality” and is associated with one or
more of the following features:
 Difficulty initiating sleep
 Difficulty maintaining sleep
 Early morning awakenings

45. Diagnostic Considerations for the
FNP
– The sleep dysfunction causes distress and interruptions in ADLs
– Sleep difficulty occurs for at least 3 times per week
– Sleep difficulty occurs for at least 3 months
– The insomnia can/cannot be attributed to substance abuse
– The insomnia can/cannot be attributed to another illness or sleep
disorder

46. Things to Remember……..
• Older adults tend to go to bed earlier and wake up earlier.
• Life style changes can impact sleep
• Sleep disturbances in older person in most cases is related to
medical or psychiatric disorder (Tusaie & Fitzpatrick, 2013)
• Comprehensive health history should be obtained, including
but not limited to: physical health history and medication
history

47. Non-Pharmalogical Treatments for
Insomnia
• Cognitive behavior therapy
• Sleep hygiene instruction
• Avoidance of stimulating substances (alcohol and caffeine)
• Reduction of environmental and stimuli (Janicak, 2011)
• These treatments may work better than pharmacological
options due decreased metabolic processes of the older adult
(APA, 2005)

48. Pharmacological Treatments for
Insomnia
• Benzodiazepines: doses should be low and length of
treatment should be short. This is due to decreased drug
clearance in older patients, Example: Triazolam
• Zolpidem, zaleplon, eszopiclone, ramelteon (prescribe in
low doses)
• Older patients should be weaned from medication slowly

49. Substance Abuse in Older Adults
• -Alcohol abuse is a significant problem for older Americans
• -17% of older adults misuse an abuse drugs and alcohol
• Alcohol abuse can cause:
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Cirrhosis
Malnutrition
Osteomalacia
Cognitive decline
• -4.4 million older adults are foreseen to need substance abuse
treatment in 2020 (Gfroerer et al., 2003)
• -“Polypharmacy” drug use
• -Older adults may dependent on “pill taking” (Tusaie &
Fitzpatrick, 2013)

50. DSM-5 Substance Related Disorders
• Alcohol/Substance Abuse
– Excessive use of alcohol leading to clinically significant
impairment or distress for 12 months
– Excessive use of substances such as opioids, hallucinogens,
cannabis, tobacco, stimulants, etc., leading to clinically significant
impairment or distress for 12 months

51. Symptoms and Diagnosing
-Symptoms:
Slurred speech
-Diagnosing:
•
Severity:
• Mild, Moderate, Severe
• Remission:
Incoordination
• Early or sustained
• Environment:
Unsteady Gait
• Controlled
• Frequency of ingestion
Nystagmus
-Alcohol/Substance Withdrawal:
• Signs and symptoms:
Impairment in memory/attention
• Nausea, vomiting
insomnia, tachycardia,
Stupor/Coma
etc.

52. Diagnostic Considerations for the
FNP
– Comprehensive physical exam with medication history
– Evaluate for underlying medical and psychological
conditions
– Situational sensitivity (Tusaie & Fitzpatrick, 2013)

53. Non-Pharmcalogical Treatments for Alcohol and
Substance Abuse
Cognitive Behavior Therapy
• Health care professionals can help older adults boost
their motivation to stop drinking, identify circumstances
that trigger substance abuse, and learn new methods to
cope with high risk drinking situations (APA, 2005)

54. Pharmacological Treatments for Alcohol and
Substance Abuse
– Precise history of drugs taken and pharmacies used by the older
patient. This will help with identifying potential adverse drug
reactions, and frequency of self-administration.
– If any medications are prescribed the provider should be
cognizant of decreased drug metabolism in older adults.
– Antidepressants and anxiolytics are occasionally used in treatment
• Dosing should be low
• Treatment should be short (Tusaie & Fitzpatrick, 2013)

55. Chronic Illness, Mental Health, and the
Older Adult
• 85% of older adults have chronic illness
• Chronic illness can be caused by alcohol and substance abuse,
poor nutrition and inactivity (Speer, 2003)
• Healthcare providers can help their patients cope effectively
with:
• Motivational interviewing
• Cognitive behavior therapy

56. Pharmacological Treatments for Alcohol and
Substance Abuse
– Precise history of drugs taken and pharmacies used by the older
patient. This will help with identifying potential adverse drug
reactions, and frequency of self-administration.
– If any medications are prescribed the provider should be
cognizant of decreased drug metabolism in older adults.
– Antidepressants and anxiolytics are occasionally used in treatment
• Dosing should be low
• Treatment should be short (Tusaie & Fitzpatrick, 2013)

57. Case Study
• 73 year old woman who presents with 2 month
history of tearfulness, loss of energy, apathy,
inability to get out of bed in the morning, and
insomnia with early morning awakenings.
• She describes increasing anxiety, an inability to
cope, forgetfulness, problems reading or even
watching TV, a 30 lb weight loss and feels very
constipated.
• She expresses a concern that something is wrong
with her stomach. Her lower back has also been
bothering her more.

58. Case Study
• She lost her husband 8 months ago and one of her
children a little over 1 year ago.
• She has a remote history of resected breast cancer
and a more recent history of thyroid cancer which
was resected 3 years ago. She also has a history of
atrial fibrillation.
• She has no past psychiatric history and has always
been able to cope with difficulties until recently.
• She is on Coumadin and a beta blocker.

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