Mallory Long, M.Div.
Caring for older loved ones while managing career, marriage, and immediate family can seem daunting as caregivers experience the shift from having an independent, healthy parent or relative to a forgetful, depressed, and dependent relative. The growing field of geriatric psychiatry can provide answers for the care giving journey and return seniors to the most optimal level of functioning possible for each individual.
Receiving an evaluation from a geriatric specialist provides a comprehensive look at the mental, physical, emotional, social, and spiritual aspects that prove to be intricately interconnected – especially in older adults. The geriatric specialist begins by exploring current physical health and history. There are a variety of physical conditions that can cause behavioral, mental, and emotional changes. These can be as simple as a urinary tract infection, Vitamin B12 deficiency, or dehydration. In an elder, these conditions can increase forgetfulness, irritability, agitation, and bring about personality changes.
As we age, we accumulate more medical conditions or, at the least, physical limitations. Elders are therefore taking more medications and are being treated by a wider array of physicians than ever before. The geriatric psychiatrist can survey particular medical conditions and their corresponding medications that may be a very large contributing factor in an elder seeming depressed, anxious, confused, etc. For example, depression is very common in those who have experienced cardiac events and are taking medications. Often, those with thyroid problems may exhibit significant depression which, when properly treated, will surprise loved ones with a return to good mental health.
The drug interaction between medications seniors are taking is key to the geriatric evaluation. Some elders can be taking so much medication, they develop a type of “delirium” which can cause disorientation, confusion, agitation, fearfulness, paranoia, etc. When medications are discontinued, the delirium subsides. Families who may have received a diagnosis of Alzheimer’s disease or dementia for their loved one can now be happily informed that the true culprit is a treatable, temporary condition.
Diagnosing depression vs. dementia is a daily function for the geriatric psychiatrist. It is a fallacy that depression is a natural part of aging. Depression is as treatable in seniors as it is in younger individuals; however, depression manifests differently in seniors. There is more irritability and restlessness associated with older adult depression. Significant changes in sleeping and eating habits can occur such as insomnia or marked decrease in appetite. Becoming extremely focused on ailments, aches and pains that are real or imagined can also be common. Social withdrawal is frequent as is forgetfulness and confusion. A senior will commonly state “I’m not depressed” even while experiencing the above symptoms.
Dementia can look almost exactly like senior depression. The geriatric evaluation will provide expertise in this area and be an invaluable tool to continue to be used by the elders’ other treating physicians and specialists. Receiving the proper diagnosis can then set the elder and caregivers on the road to proper treatment.
If the caregiver learns the elder has depression and not dementia, treatment can then include antidepressants and supportive counseling that addresses changes in life such as retirement, death of a spouse or other family/friends, geographic moves out of the family home, decreases in social activity, etc. Spiritual concerns, such as lack of purpose and a feeling of being “useless” as a result of physical and mental limitations are explored.
For the caregiver, the maze of changes, symptoms, and decisions ahead can lead one to question who can provide guidance with so many factors and medical professionals involved. The geriatric psychiatrist and other geriatric team members are available to meet this need.
Ridgeview Institute is a private behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for children, adolescents, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775.
For more information about the Ridgeview Institute’s Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.
Nancy L. Kriseman, L.C.S.W.
“We live by losing, leaving, being left and letting go, and sooner or later with more or less pain, we all must come to know that loss is indeed a lifelong human condition.”
Judith Viorst, author of Necessary Losses
No one is more familiar with the above words than elders, who, by virtue of their age, are survivors of loss and recognize that indeed loss is a lifelong human condition.
The twenty-first century will see a tremendous growth in our elder population, from the current rate of about 12 percent to 20 percent, with the fastest growing segment of our population being the 85-plus group! Those of us who choose to work with this population know there are a plethora of issues and challenges that families face as their family members enter this new and unique stage of the lifecycle.
Understanding How Loss Impacts Elders
Elders experience loss quite differently than younger people. Because of increased longevity, later life losses assume a central role in an elder’s life.
Older people experience accumulated losses, which are many and varied. Elders experience personal relationship losses of friends, siblings, children, and spouses; physical losses, such as loss of bodily functions, loss of energy, and loss of sensory deficits; or financial losses that result from retirement or health problems. All these losses can contribute to loss of their home, car, independence, and role.
Gerontologists have found that these accumulated losses lead to bereavement overload. Bereavement overload is defined as an experience that leaves an elder feeling overloaded by multiple losses, while having less emotional, physical and financial resources to cope with them. It is important to be aware that bereavement overload can contribute to depression and extended grief. Thus, therapists when working with elders around loss issues will need to help elders identify how bereavement overload is impacting their lives and then help them secure resources and support that address these challenges. Furthermore, it is important to educate the adult children about what bereavement overload is and how they might support their family member.
Generational differences are another example of how loss is different for elders. Mary Pipher in her book, Another Country, illustrates how elders live in “another country.” The ways of the past are much different from the present she states. Mary Pipher defines these generational differences as different landscapes between the generations. These landscapes impact the ways different generations adapt to situations, emotions, and events in their lives. She states that as therapists it’s important to help families understand how these different landscapes play out in their lives. For example: The landscape of death and coping with loss was much different during the years elders were young adults. Elders experienced loss early on in their lives, and to them, loss was just a natural part of life. Elders in their 80’s and 90’s were intimately involved in the entire dying process from onset of the illness to the burying of the body. On the contrary, the baby boomer generation and younger generations of today have had much less experience with death early on and tend to view death more from the sidelines, (ie. what they are exposed to on TV, movies etc.).
Another example of landscape differences involves how the different generations were raised to express feelings. The emotional landscape for elders in their 80’s and 90’s involved different rules and ways of expression. I have been told over and over by elder clients that when someone was dying or died, they were told to keep their grief to themselves and just “tough it out.” Thus, the idea of talking with a therapist or adult child about loss or death would be considered almost a sin. Yet the emotional landscape of the younger generations of today, tend toward being more open to expressing their feelings about death and loss to professionals, therapists, rabbi’s, ministers, in support groups and to friends. When the two meet, there can be a great divide!
So How Do Therapists Intervene????
While it may not be possible to merge the different landscapes of the generations, there are effective ways to help create more awareness and understanding of these differences.
Therapists who work with elders and their families have the privilege of supporting and helping these families finish well.
Family therapist, Dr. Terry Hargrave, coined the phrase “finishing well” to mean coming to terms with the potential end of life. To encourage elders to finish well involves helping them recognize the meaning and value in their lives. To encourage families to finish well involves helping them attempt to come to terms with the eventual loss of their elder family member.
Therapists walk a fine line when helping elders and families finish well as generational differences can produce some intense feelings. Therapist are challenged with helping to validate their feelings and at the same time, temper some of the frustration, fear, sadness and anger they may both share.
One of the most effective approaches to helping families cope with the necessary losses that the elder years bring, is to utilize the genogram. The genogram is a wonderful tool that graphically helps elders and their families view their family tree on paper. It provides a way for elders and their families to talk about their lives together or to life review. Life review allows the elders and their families to validate their lives, and acknowledge the good, the bad and the ugly! It is not uncommon to discover unfinished business, (which are the emotional leftovers that still feel unsettled or cause frustration, stress, or depression.). It is important to note that sometimes there might be some unfinished business that cannot be resolved, and then it becomes the therapist’s job to help them make peace with or at least acknowledge the business that cannot be finished.
Another common issue that surfaces during life review is the role changes that occur in the family system. I have found many families become stuck as they try to hold onto the way their roles used to be. Elders fear losing control and being a burden. At the same time, adult children often experience conflictual feelings about the changes they see occurring in their elder family member and how to reconcile those changes in their hearts. They struggle with when to take over and when to let go. It is the goal of the therapist to help families shift into these different roles, not reverse the roles. Healthy role change involves allowing the elders and their families the opportunities to share what they miss about the old roles and give them permission to grieve.
Last, but not least importantly, is the recognition of the role that spirituality plays in this stage of life. Many studies have found elders embrace their spirituality at the end of life and are indeed even more spiritual at the end of life.
Spirituality helps them find meaning and hold onto hope. It frames their past, present and future. It helps them to shift from being outer focused to being more inner focused; to let go of ego and embrace soul.
I believe it is important for therapist to help elders find as many paths to their spirituality as possible. We need to keep them connected to their faith communities, to nature, to people, to their hearts. We need to pray with them, listen to them, sing with them and just “be” with them. We need to encourage families to connect to their own spirits and the spirits of their elders and shift from “doing” to “being.” We need to encourage families to utilize their spiritual resources and expand them as well.
As author Ram Dass says in his book, Still Here, “Wisdom requires that we relax our hold on our picture of how things ought to be and learn to make peace with things as they are. We can only do this moment by moment, here and now, responding with open hearts and minds to the changes that occur.”
It is the task of the therapist to help open the hearts of both the elders and their family members.
Loss can be life changing and bring forth-incredible meaning and value. Old age does not have to be a “wait for the end” or a “time of despair.”
Judith Viorst, Necessary Losses Fawcett Gold Medal, New York 1986 Ram Dass, Still Here Riverhead Books New York, 2000
Rachel Naomi Remen MD, My Grandfathers Blessings Riverhead Books New York, 2000 Randy Gerson & Monica McGoldrick Genograms
Nancy L. Kriseman L.C.S.W. is a licensed social worker who specializes in counseling and consulting with elders and their families. She also provides training and in-services for long- term care environments. Ms. Kriseman has been in private practice for over 12 years and has worked in the field of aging for 21 years.
Ms. Kriseman has been on the faculty at Kennesaw State University as adjunct professor for 12 years and teaches two courses, “Aging and the Family” and “Death and Dying”.
Ms. Kriseman is currently working with Health Professions Press on a book to be published entitled, “The Caring Spirit” for family and professionals caregivers, which will be available the beginning of 2005.
Ms. Kriseman holds a Masters in Social Work and Specialist in Aging Degree from the University of Michigan, 1982. She has her BA degree from the University of Florida, which she obtained in 1979.
GERIATRIC CONSULTING SERIVCES INC.
Nancy L. Kriseman L.C.S.W. PO Box 8273 Atlanta, GA 31106
Ridgeview Institute is a private, not-for-profit behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for children, adolescents, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775.
For more information about the Ridgeview Institute’s Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.
By Donna McGrane, RN, Ridgeview Institute Community Relations Representative
Believe it or not, there is a growing epidemic for older adults – the incidence of substance abuse. Yes, Mom, Dad and Grandparents alike suffer from substance abuse including alcohol and prescription drugs, at a rate of up to 17% of adults age 60 and over. It is a serious problem that is typically ignored.
Identifying either an alcohol or prescription abuse problem in an older adult is very difficult. Symptoms of insomnia, poor concentration and coordination, confusion and depression are regularly blamed on “old age.”
Barriers to identifying substance abuse in this age group are that older adults are often isolated in their home or far from family. They are not in the work force where poor performance could be noticed. Many seniors do not drive. This is a generation who views alcoholics as the “guy under the bridge,” and see alcoholism as a moral and character issue full of shame and denial.
This generation did not grow up in the self-help age, sharing feelings, telling secrets. They are part of the “Greatest Generation”. They solve problems, have experienced war and economic depressions and most importantly, believe in God and America. They don’t discuss their problems, rather they were taught to “pull up their boot straps and go on.” Communication about issues and emotions were rarely front and center to the profile of our parents and grandparents.
There are two types of alcoholism in the older adult. Early onsets are the adults who have suffered with the disease and have been drinking most of their life. This accounts for two thirds of the older alcoholics. Late onset alcoholism occurs in one third, who drink excessively later in life, often following a significant loss or life change, such as the death of a spouse or retirement from a long term career and organization that defined them in society.
Financial problems, estrangement from family, isolation and loneliness, changing body chemistry, chronic pain, depression, losses, boredom, and a history of substance abuse are all contributing factors to alcoholism later in life.
Family dynamics, attitudes and the stigma of addiction also contribute to the older adult not getting help. “Why deprive them – they haven’t got long to live” or “It is Mom’s only pleasure,” or “Dad’s too old to change – he’s been drinking all his life.”
Prescription drug abuse is also an epidemic problem. More than 83% of older adults over age 60 are prescribed at least one medication, and over 50% of those are sedatives. Many older adults see multiple physicians, and take an average of 13 prescriptions annually, in addition to over-the-counter medications. The belief that if a doctor prescribed a “medicine” it has to be effective and it has to be OK. Adverse drug reactions from polypharmacy and co-morbid health conditions can mimic or mask symptoms of addiction.
Older adults do have health problems and adverse medical conditions. Their bodies absorb, metabolize, distribute and eliminate drugs differently than younger people, so a “normal” dose can cause toxicity and dangerous side effects. Adding alcohol to the mix, over-the-counter medications, emotional, financial and social factors, losses and life style changes increase the risk of addiction. Alcohol and prescription abuse can lead to depression, dramatic personality changes, memory loss, malnutrition, falls, and several forms of cancer, heart disease and early death. Many times regular exercise and solid dietary regiments have fallen by the wayside in older adults weakening further the physical counteraction to drugs and alcohol.
The misuse of alcohol and prescriptions can also worsen diseases normally associated with aging, including heart and liver disease, diabetes, arthritis, gastrointestinal disorders, hearing loss, cataracts and dementia.
Here are some signs you may notice:
- Drinks in a solitary, hidden way.
- Makes a ritual of having drinks before, with or after dinner and becomes annoyed when this routine is disturbed.
- Drinks in spite of warning labels on prescription drugs.
- Is often intoxicated or tipsy, displays slurred speech.
- Is neglecting personal appearance, gaining or losing weight.
- Often has the smell of alcohol or mouthwash to disguise it.
- Complains of sleeplessness, loss of appetite, chronic health complaints.
- Has unexplained burns, bruises or tries to hide them.
- Seems more depressed or hostile than usual.
- Can’t handle routine chores, paperwork without mistakes.
- Has irrational or undefined fears, delusions, unusual stress or loss of memory.
Adults are living longer, so addressing these issues in someone in their 70’s can mean they may have another 5, 10 or even 20 years of improved physical, emotional and spiritual health. Older adults have the highest recovery rate of all age groups. A key factor in the recovery of an older adult is the concern and involvement of family and friends. Unfortunately, 90% of older adults at risk never receive help.
If you suspect a family member or friend who may have an alcohol or prescription drug problem, take that first step to getting them help and a thorough evaluation.
It is important to take into consideration the person’s age and ability to understand. Be gentle and loving, avoid confrontation, and avoid using the terms “alcoholism” or “drug addiction” since these carry a heavy stigma. Focus on the present issues and effects on their life now, do not dig up issues from the past. Be direct, be specific, and use “I” phrases such as “I have noticed,” or “I am worried,” so the older adult can’t argue with your feelings.
Mom with a substance abuse problem? Maybe!
Ridgeview Institute, located at 3995 South Cobb Drive, Smyrna, Georgia, is a private, not-for-profit provider of psychiatric and addiction treatment, including inpatient, partial hospitalization, and intensive outpatient treatment options for youth, young adults, adults, and seniors. We offer specialty programs for Impaired Professionals, Eating Disorders, Young Adults, and Seniors. For more information on Ridgeview’s programs and services please call (770) 434-4567 or visit our website at www.ridgeviewinstitute.com.