Counseling older adults: A review

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Counseling older adultsA review

• Ryan Berg
• October 13, 2007

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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

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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)

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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!

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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

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Whats the problem with these stereotypes? (cont)

• They are pervasive and infectious
• Believed by adults, doctors, health care
  providers, families, caregivers, and OAs
  themselves!

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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

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Common factors that lead to disorders

• Loss
• Bereavement
• Loneliness
• Adjustment issues
• Physical decline
• Somatic illness (heart, respiratory, vascular,
  etc.)
• Normal issues we all face

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What are the most common disorders?

• Depression (both major and minor)
• Anxiety
• Cognitive Alzheimers Disease (dementia)

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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

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Depression (cont)

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

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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

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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

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Cognitive Alzheimers (dementia) (cont)

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

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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

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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

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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

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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

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Treatment Anxiety (cont)

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

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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)

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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

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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.)

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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)

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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

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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

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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

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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)

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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

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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

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Barriers to treatment OAs (cont)

• Internalized ageism and beliefs about old age
• Tend to not perceive need for mental health
  help/disorder
• Communication problems

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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.

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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)

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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!

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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!

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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

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Questions?

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