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Counseling older adults: A review

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Intern at Sound Mental Health, Older Adult Services. Intend to work with older ... Chad Boult, Johns Hopkins' geriatric professor, when asked about what can be ... – PowerPoint PPT presentation

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Title: Counseling older adults: A review


1
Counseling older adultsA review
  • Ryan Berg
  • October 13, 2007

2
Who am I?
  • Grad student at Seattle University
  • Pursuing M Ed., MHC degree
  • Intern at Sound Mental Health, Older Adult
    Services
  • Intend to work with older adults in my career

3
What is an older adult (OA)?
  • 60-years old and up
  • Current cohorts
  • Greatest (G.I.) Generation (1911-1924)
  • Silent Generation (19251942)
  • Baby Boomers (1940s-1964)

4
What are some societal stereotypes?
  • Serious decline of mental functions happens with
    age (dumbing down is natural)
  • No need for counseling/counseling ineffective for
    OAs
  • Typically alone or abandoned
  • Natural for some depression to set in OAs not
    young anymore
  • Bodies and minds are failing, of course theyre
    bitter and sad!

5
Whats the problem with these stereotypes?
  • They can be dangerous and untrue
  • Prevent people with potential issues from
    reporting and seeking diagnosis
  • Nearly 20 of OAs experience mental disorders
    that are not a part of normal aging
  • OA experience not one size fits all
  • There are many OAs who adjust and are happy with
    their lives
  • Others may need a little or a lot of help,
    depending

6
Whats the problem with these stereotypes? (cont)
  • They are pervasive and infectious
  • Believed by adults, doctors, health care
    providers, families, caregivers, and OAs
    themselves!

7
Some numbers to consider
  • According to 2000 U.S. census
  • 19,546,252 men over the age of 60
  • 26,250,948 women over the age of 60
  • Total number 45,797,200
  • This will only increase as time passes
  • In 2007, as many 50-year olds as 5-year olds
  • In 30 years, as many people over 80 as under 5

8
Common factors that lead to disorders
  • Loss
  • Bereavement
  • Loneliness
  • Adjustment issues
  • Physical decline
  • Somatic illness (heart, respiratory, vascular,
    etc.)
  • Normal issues we all face

9
What are the most common disorders?
  • Depression (both major and minor)
  • Anxiety
  • Cognitive Alzheimers Disease (dementia)

10
Depression
  • The most common mental illness for OAs
  • Anywhere from 8-20 (community) to 17-37
    (general care)
  • Suicide correlates with depression in
    approximately 90 of cases!
  • Suicide is the greatest in this group among all
    age groups (especially men)
  • Also can impair overall physical, mental, and
    social functioning
  • Depression often leads to other problems or
    exacerbates them

11
Depression (cont)
  • Major not as common, but minor is pervasive
  • Depression NOS
  • Dysthymia
  • Often goes undiagnosed and untreated

12
Anxiety
  • 5.5 of people over 65 suffer from some form of
    anxiety disorder (phobia, panic, OCD, PTSD, GAD)
  • Comorbidity with depression is very common
  • 2/3 with anxiety disorder have major depressive
    episode
  • 38 of major depressed have at least one anxiety
    disorder
  • Also contributes to cognitive problems
  • Often goes undiagnosed and untreated

13
Cognitive Alzheimers (dementia)
  • Majority of late-life dementia is associated with
    Alzheimers Disease (AD)
  • Alzheimers affects 8-15 of OAs
  • Difficult to diagnose and determine type of
    dementia
  • Many types are similar and onset is usually
    gradual

14
Cognitive Alzheimers (dementia) (cont)
  • Other types include
  • Mild Cognitive Impairment (MCI)
  • Lead in to AD?
  • Vascular Dementia (VD)

15
Treatment Depression
  • Pharmacological
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Monoamine oxidase inhibitors (MAOIs)
  • Tricyclics (TCAs)
  • Psychotherapeutic
  • Typically done in concert with pharmacological
    treatment
  • Most commonly used therapies
  • Cognitive-behavioral (CBT)
  • Reminiscence and life review (RT)
  • Brief psychodynamic
  • Interpersonal

16
Treatment Depression (cont)
  • Electroconvulsive therapy (ECT)
  • Performed when medications and/or psychotherapy
    dont work
  • Preferable when need for suicidal relief is
    immediate
  • Considerations
  • For OAs, medication can take 8-12 weeks to work
  • Side-effects can be dangerous
  • Polypharmacy

17
Treatment Depression (cont)
  • Good news Depression is very treatable (70-80
    recovery rate) especially when psychopharmacologic
    al approach is used
  • Bad news This only matters when OA is diagnosed
    and treated

18
Treatment Anxiety
  • Pharmacological
  • Benzodiazepines (Xanax, Valium, Ativan)
  • Immediate but short-term relief (acute)
  • Risk of addiction
  • Buspirone (Anxiron, BuSpar, Narol)
  • Better for chronic treatment
  • May take up to 4 weeks before taking effect
  • SSRIs (usually in concert with benzos)
  • Side effects should be considered in all cases

19
Treatment Anxiety (cont)
  • Psychotherapeutic
  • Not much examination done thus far
  • Typically involves cognitive-behavioral (CBT) or
    behavioral (relaxation and meditation training)
    approaches

20
Treatment Alzheimers (dementia)
  • Best treatment Early detection!
  • No cure, but delay is better than full onset
  • Possible protective factors for onset
  • Nonsteroidal anti-inflammatories
  • Estrogen replacement
  • Vitamin E
  • Selegiline (deprenyl)

21
Treatment Alzheimers (cont)
  • After onset
  • Acetylcholinesterase (AChE) inhibitors
  • Antipsychotic and antidepressant medication
    (behavioral)
  • Psychotherapeutic
  • Focus is on behavioral more than mental,
    depending on state of OA
  • Typically RT with some CBT for depression and
    anxiety
  • Key for caregivers to receive education and
    therapy as well!
  • CBT and interpersonal most frequently used for
    therapy

22
Most commonly used psychotherapy modalities
  • Cognitive-behavioral (CBT)
  • Reminiscence and life review (RT)
  • Brief (short-term) psychodynamic
  • Behavioral
  • Interpersonal
  • Solution-focused
  • Eclectic (existential, humanist, gestalt, etc.)

23
Common therapeutic styles
  • Individual counseling is primary means
  • Tends to be preference for OAs
  • Done in private homes, mental health centers,
    nursing homes, assisted living, private practice
    offices, etc.
  • Group therapy not as utilized
  • Typical modalities include interpersonal, RT, or
    buffet (eclectic) combinations
  • When done, usually takes place in residential
    settings (assisted living, nursing home)

24
Common therapeutic styles (cont)
  • In either case, family support is key, especially
    with depression or AD
  • Tracking medications, helping establish and keep
    goals, keeping appointments, and general support
  • However, psychotherapy with OAs is still not well
    researched
  • To this day, still debate over whether its
    effective, feasible, and appropriate
  • Slowly changing, may (hopefully!) change more
    with Boomers

25
How is counseling for OAs different from other
groups?
  • Somatic/psychological ties are very pronounced
  • OAs often speak of their ailments in terms of
    somatic illnesses first, mental/emotional
    problems next
  • Life stages and transitions can be especially
    large and cumbersome
  • Loss of partner, loved ones, and friends/social
    network
  • Adjustment (retirement, living circumstances)
  • Loss of autonomy and self-determination

26
How is counseling for OAs different from other
groups? (cont)
  • Counselor must be aware of cognitive and physical
    limitations
  • Some (not most!) OAs have reduced capacity for
    processing immediate information
  • Perception (hearing and sight) issues
  • Environmental factors (extraneous noises
    distracting)
  • Counselor should be aware of possible
    transference and countertransference issues
  • Need for respect for OA life station
  • OA not limited, just in different phase of life

27
Barriers to treatment Medical/Clinical
  • Under-recognition of mental illnesses by doctors
  • Multiple illnesses distract from mental concerns
  • Depression, anxiety, and memory problems seen as
    normal for OAs
  • Without mental health or geriatric training may
    not recognize mental illness from normal aging
  • Time constraints with patients
  • Focus on alleviating somatic complaints (symptoms)

28
Barriers to treatment Medical/Clinical (cont)
  • Communication problems
  • Doctors often believe any patient concerns should
    be spoken to during first appointment
  • Patient wants rapport to develop and then doc to
    ask questions once trust is developed
  • Doctors tend to refer only to psychiatrists, not
    other mental health clinicians or resources
  • Referrals still rare from primary care provider
    (PCP)
  • Cost of treatment/managed care limitations
  • Not all practitioners can bill Medicare, for
    example

29
Barriers to treatment OAs
  • Stigma
  • Only 10 in need go and get it
  • Some signs this is changing
  • Physically aligned, not mentally aligned
  • Time with single physician limited
  • OAs most often seek mental health help from
    primary care provider
  • The average OA who commits suicide saw PCP within
    2 weeks of committing act

30
Barriers to treatment OAs (cont)
  • Internalized ageism and beliefs about old age
  • Tend to not perceive need for mental health
    help/disorder
  • Communication problems

31
Where is the rest of medicine?
  • In trouble
  • Number of certified geriatricians fell by 1/3
    between 1998-2004, and specialty applications are
    plummeting
  • 97 of current medical students take no
    geriatrics courses
  • Chad Boult, Johns Hopkins geriatric professor,
    when asked about what can be done to ensure there
    are enough geriatricians for surging elderly
    population Nothing. Its too late.

32
Other considerations
  • Most study material is with Silent Generation
    (19251942)
  • Boomers may change the game quite a bit in terms
    of expectations
  • Issues among OAs can be very different depending
    on age
  • Young-old (60-75)
  • Middle-old (75-85)
  • Very-old (85-up)

33
Other considerations (cont)
  • Very understudied population!
  • Not nearly enough research done, especially on
    modalities for treatment and psychopharmacological
    approaches
  • If its only now as a society we begin to value
    and study OA counseling, were already very far
    behind!

34
Where should we go?
  • Have specialized geriatric counseling training
    programs for counselors
  • Include basic geriatric medical training for
    pharmacological background and physical concerns
  • Cover specialized therapeutic concerns for OAs
  • How to establish and nourish therapeutic
    relationship
  • Have other care providers train in basic
    geriatric counseling
  • Nurse practitioners
  • Social workers
  • Case workers
  • Even (and especially) physicians!

35
Where should we go? (cont)
  • More studies and more styles
  • Research on individual, group, family, and
    couples counseling
  • Seeing OAs as everyone else in terms of
    counseling!
  • Different therapies need to be investigated
  • More than just CBT and RT

36
Questions?
  • You can reach me at
  • bergm1_at_seattleu.edu
  • Thanks very much!!!
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