Chapter 27
Mental Health Disorders
Terms to Know
Emotional homeostasis: balance of emotions
Pseudodementia: false appearance of dementia that
occurs when persons demonstrate cognitive deficits
secondary to being depressed
Substance abuse: inappropriate or excessive use of
alcohol, caffeine, cannabis, hallucinogens, inhalants,
opioids, sedatives, hypnotics, anxiolytics,
stimulants, tobacco, and other or unknown
substances that result in disorders
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Introduction
 Mental health indicates a capacity to cope effectively with and
manage life stressors in an effort to achieve emotional
homeostasis
 Life experiences give older adults an advantage in dealing with
stressors
 Unique strengths, losses, and challenges
 May bring past mental problems into later lifetime
 Losses and challenges may exceed physical, emotional, and
social resources, contributing to mental illness
 Need to promote mental health, detect problems early, and
minimize the impact of existing psychiatric problems
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Aging and Mental Health #1
 Myths and stereotypes
o Loss of cognitive function a normal part of aging
o Pathological signs considered normal, no attempt made to
intervene
 Cognitive function in later life is highly individualized
 Incidence rising among older adults
o 1 in 4 experience some mental disorder: depression,
anxiety disorders, substance use disorders, dementia
o Expected to be 15 million by 2030
o 2/3rds of older adults do not seek treatment
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Aging and Mental Health #2
Depression prevalence
o 7 million older Americans
Suicide
o Aged 85 and above highest rate of any age
group (per capita)
o Older white men almost 6x general population
Loss of multiple loved ones, altered sensory
function, and alterations, discomforts, and demands
associated with multiple chronic conditions set stage
for variety of mental health problems
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Promoting Mental Health in Older Adults
#1
Mental health implies satisfaction and interest in life
No single profile for mental health
Assessment should be objective and unbiased
Good mental health practices throughout a lifetime
promote mental health in later life
Need to maintain satisfying interests and activities
Opportunities to sense value as a member of society
and have self-worth reinforced
Security to meet basic human needs
Support and assistance through stressful situations
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Promoting Mental Health in Older Adults
#2
Connection with others
Importance of optimum physical health
Principles guiding care
o Strengthen individual’s capacity to manage
condition
o Eliminate or minimize limitations imposed by
condition
o Act for or do for the individual only when
absolutely necessary
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Promoting Mental Health in Older Adults
#3
Problems that older adults confront that may
challenge emotional homeostasis
o Illness, death, retirement, increased
vulnerability, social isolation, sensory deficits,
greater awareness of own mortality, increased
risk of institutionalization, dependency
Assess symptoms as they may be “normal”
reactions to life circumstances (DABDA might be in
progress)
Address the cause of the problem rather than
effects/symptoms alone
Need for accurate and astute assessment
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Nursing Problems Related to Mental
Health Problems #1
Difficulty engaging and participating in activities
o Causes: depression, lack of motivation, sensory
overload, fatigue, medications
Anxiety
o Causes: threat to self-concept, losses
Constipation
o Causes: psychomotor slowing, medications,
inactivity, lack of recognition of need to defecate
Diarrhea
o Causes: anxiety, medications, stress
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Nursing Problems Related to Mental
Health Problems #2
Pain (acute or chronic)
o Causes: hyperactivity, sensory overload, suicidal
attempt
Difficulty communicating with others (verbally,
nonverbally)
o Causes: impaired cerebral function, anxiety,
suspiciousness
Difficulty coping
o Causes: stress, altered body function, low selfesteem, dependency, sensory overload, loss of
significant other
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Nursing Problems Related to Mental
Health Problems #3
 Difficulty coping with family-related issues
o Causes: patient dependency; history of poor family
relationships
 Difficulty participating in activities
o Causes: physical, mental, or social limitations
 Fear
o Causes: new or misperceived environment, losses
 Difficulty managing and completing health and home
maintenance tasks
o Causes: cognitive impairment, misperceptions, lack of
motivation
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Nursing Problems Related to Mental
Health Problems #4
Potential for infection
o Causes: medications, inactivity, inability to
protect self
Potential for injury
o Causes: cognitive impairment, fatigue,
medications, suicidal attempt
Impaired physical mobility
o Causes: medications, fatigue
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Nursing Problems Related to Mental
Health Problems #5
Noncompliance
o Causes: cognitive impairment, lack of motivation
or capacity, suicidal desires
Malnutrition; dehydration; weight gain or weight
loss
o Causes: depression, anxiety, stress, paranoia,
cognitive impairment, suicidal attempt
Powerlessness
o Causes: paranoia, depression, disability, stress
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Nursing Problems Related to Mental
Health Problems #6
Difficulty completing self-care activities including
ADLs and/or IADLs
o Causes: cognitive impairment, lack of
motivation, knowledge, skill
Altered body image
o Causes: change in body appearance or function,
losses, ageism
Sexual dysfunction
o Causes: depression, anxiety, paranoia, guilt,
stress, altered self-concept, medications
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Nursing Problems Related to Mental
Health Problems #7
Difficulty sleeping; insomnia
o Causes: anxiety, paranoia, depression,
confusion, medications
Difficulty interacting with others
o Causes: altered body part or function, cognitive
impairment, anxiety, depression, misperception,
paranoia
Social isolation
o Causes: anxiety, depression, paranoia, cognitive
impairment
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Nursing Problems Related to Mental
Health Problems #8
Difficulty engaging and socializing with others
o Causes: cognitive impairment, fear, depression,
anxiety, stress, isolation, inattention, paranoia,
substance use/misuse
Urinary incontinence; urinary frequency; urinary
retention
o Causes: cognitive impairment, anxiety,
depression, medications
Potential for self-directed or other-directed violence
o Causes: cognitive impairment, paranoia, stress,
misperceptions, fear, suicidal attempt
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Depression #1
Most frequent psychiatric problem treated in older
adults
o Major versus minor depression
Incidence/prevalence
o Depressive symptoms: 15% in communitybased older adults
o Major depressive disorder: 6% to 10% of
community-based; 12% to 20% of nursing
home residents; 11% to 45% of acute care older
adult patients
May be a lifelong problem or new onset in old age
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Depression #2
Various drugs may cause or aggravate depression
o Antihypertensives, cardiac drugs: beta-blockers,
digoxin, procainamide, guanethidine, clonidine,
reserpine, methyldopa, spironolactone
o Hormones: corticotropin, corticosteroids,
estrogens
o CNS depressants, antianxiety agents: alcohol,
haloperidol, flurazepam, barbiturates,
benzodiazepines
o Others: cimetidine, L-dopa, ranitidine,
asparaginase, tamoxifen
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Depression #3
Signs and symptoms
o Most common: insomnia, fatigue, anorexia,
weight loss, constipation, lack of interest in
activities previously enjoyed, decreased interest
in sex
o May express self-deprecation, guilt, apathy,
remorse, hopelessness, helplessness, feelings of
being a burden
o Problems with personal relationships and social
interactions
o Changes in sleep and psychomotor activity
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Depression #4
Signs and symptoms (cont.)
o Hygiene neglect
o Physical complaints: can include headache and
indigestion
o Altered cognition
 Can mimic dementia
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Depression #5
 Assessment
o Crucial to avoid misdiagnosis
o During routine health visits
o Short assessment tools
o Missed diagnosis factors
o Atypical presentation of symptoms
o Assess relationship of life events and/or serious or
terminal illness with depression
o Assess underlying problem
o Prompt treatment can hasten recovery
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Depression #6
Treatment/management
o Psychotherapy
o Antidepressants
 SSRIs: escitalopram (Lexapro),
fluvoxamine, fluoxetine (Prozac),
paroxetine, sertraline (Zoloft)
 Cyclic compounds: amoxapine, desipramine
HCl, doxepin HCl, imipramine pamoate,
nortriptyline HCl
 MAOIs: phenelzine, tranylcypromine
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Depression #7
Treatment/management (cont.)
o Nursing Guidelines for Antidepressants
 Begin with lowest dose and frequency
 Sedation common during initial treatment; fall
precautions necessary
 Usually requires 1 month of therapy
before therapeutic effects noted
 Bedtime administration preferred
 Be alert for anticholinergic symptoms (cyclic
compounds)
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Depression #8
Treatment/management (cont.)
o Nursing Guidelines for Antidepressants (cont.)
 Potential adverse events: dry mouth,
diaphoresis, urinary retention, indigestion,
constipation, hypotension, blurred vision,
drowsiness, increased appetite, weight gain,
photosensitivity, fluctuating blood glucose
levels
 Ensure older adults and caregivers understand
dosage, intended effects, and adverse
reactions to drugs; instruct about drug–drug
and drug–food interactions
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Depression #9
Treatment/management (cont.)
o Electroconvulsive therapy
o Herbs
 St. John’s wort
o Complementary/alternative (CAM) therapies
 Acupressure, acupuncture, guided imagery,
light therapy
 Growing acceptance: psilocybin and other
hallucinogens at end of life
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Depression #10
Treatment/management (cont.)
o Good basic health practices
 Help patient develop a positive self-concept.
 Encourage expression of feelings.
 Avoid minimizing feelings.
 Ensure that physical needs are met.
 Offer hope.
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Depression #11
 Suicide risk
o Real and serious risk
o Incidence/prevalence
 Highest for all males among aged 75 and older
 Highest for all females among aged 75 and older
o Risk factors: previous suicide attempt(s), family history of
suicide, history of alcohol and/or substance abuse,
isolation, barriers to accessing mental health treatment,
physical illness, easy access to lethal methods,
unwillingness to seek help
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Depression #12
Suicide risk (cont.)
o Protective factors:
 Access and effective clinical care; family and
community support; skills in problem solving,
conflict resolution, nonviolent ways of
handling disputes; cultural and religious
beliefs that discourage suicide
o Take all suicide threats (obvious and subtle)
seriously
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Depression #13
Suicide risk (cont.)
o Suicide gestures:
 Medication misuse
 Self-starvation
 Activities that oppose a therapeutic need
 Activities that threaten a medical problem
 Subjecting oneself to unnecessary risks
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Depression #14
Needs of suicidal older adults
o Close observation
o Careful protection
o Prompt therapy
o Treatment of underlying depression
o Environmental safety
o Nurses’ willingness to listen and discuss
thoughts and feelings related to suicide
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Anxiety #1
 Causes:
o Adjustments to physical, emotional, and socioeconomic
limitations in old age; new problems frequently
encountered with aging
 Clinical manifestations:
o Somatic complaints, rigidity in thinking and behavior,
insomnia, fatigue, hostility, restlessness, chain-smoking,
pacing, fantasizing, confusion, increased dependency;
increase in blood pressure, pulse, respirations,
psychomotor activity, frequency of voiding; change in
appetite; intensively involved with minor task; difficulty
concentrating on activity at hand
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Anxiety #2
Treatment/management
o Depends on underlying cause
o Look for recent changes or new stresses
o Review consumption of alcohol, caffeine,
nicotine, OTC drugs
Nursing interventions
o Medications, biofeedback, guided imagery,
relaxation therapy, psychological therapy
o Control environmental stimuli
o Plan interventions specific to underlying cause
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Anxiety #3
 Nursing interventions (cont.)
o Allow adequate time for conversations, procedures, other
activities
o Encourage and respect patients’ decisions over matters
affecting their lives
o Prepare patients for all anticipated activities
o Provide thorough, honest, and basic explanations
o Control number and variety of persons with whom patients
must interact
o Adhere to routines
o Keep and use familiar objects
o Prevent overstimulation of the senses
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Substance Abuse #1
 Often a problem that goes unnoticed in the older adult
 Threatens physical, emotional, and social health
 Potential for adverse drug consequences
 Increases risk for falls, decreased cognition, abuse, and selfneglect
 Chronic abuser versus situational abuser
 Health care professional stereotyping
 Substance abusers come in many forms
 Can cause medical problems: GI bleeding, hypertension,
muscle weakness, peripheral neuropathy, susceptibility to
infections
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Substance Abuse #2
Alcohol use or misuse
o May manifest in variety of ways, can be subtle
or confused with other disorders
o Possible indications of alcohol abuse: drinking to
calm nerves or improve mood; gulping or rapidly
consuming alcoholic beverages; memory
blackouts; malnutrition; confusion; social
isolation and withdrawal; disrupted
relationships; arrests for minor offenses;
anxiety; irritability; depression; mood swings;
lack of motivation or energy; injuries, falls;
insomnia; GI distress; clumsiness
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Substance Abuse #3
 Alcohol use or misuse (cont.)
o Symptoms can develop secondary to complications from
alcoholism: cirrhosis, hepatitis, chronic infections
o Screening tools
o Criteria for diagnosing alcoholism
 Drinks fifth of whiskey per day or equivalent in wine or
beer
 Alcoholic blackouts
 Blood alcohol level >150 mg/100 mL (Translates to
0.15)
 Withdrawal syndrome
 Continued drinking despite advice or problems
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Substance Abuse #4
Treatment/management
o Long-term goal is sobriety
o Patient must acknowledge the problem and take
responsibility
o Family involvement in the treatment plan
o Medication monitoring
o Alcoholism treatment programs for older adults
are rare
 Alcoholics Anonymous
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Paranoia #1
 Occurs for multiple reasons
o Sensory losses, may cause environment to be
misperceived
o Illness, disability, living alone, and limited budget promote
insecurity
o Ageism within society sends negative message about
aging
o Victims of crime and unscrupulous practices
 Conditions affecting physical health can contribute
o Chronic conditions become acute
o Adverse response to medications
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Paranoia #2
Need to explore mechanisms to reduce insecurity
and misperception
o Believes food is poisoned; sleep deprivation;
health care provider is trying to hurt them
Interventions
o Psychotherapy and medications are used when
other interventions unsuccessful
Treatment/management
o Honest, basic explanations and approaches are
beneficial
o At no time should delusions be supported
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Nursing Considerations for Mental Health
Conditions #1
Monitoring medications
o May bring significant improvement
o Potential for adverse effects: anorexia,
constipation, falls, incontinence, anemia,
lethargy, sleep disturbances, confusion
o Use the lowest possible dosage
o Monitor for problems (see Table 27-2)
o Complement other forms of treatment
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Nursing Considerations for Mental Health
Conditions #2
Promoting a positive self-concept
o People need to feel their lives have had meaning
and that there is hope
o Take interest in the lives and accomplishments
of the older adult
o Promote self-esteem
o Life review, oral histories, and scrapbook of life
events may assist in the sense of worth
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Nursing Considerations for Mental Health
Conditions #3
Promoting a positive self-concept (cont.)
o Encourage participation in relevant activities
o Ensure engagement in meaningful social
interactions
o Have opportunities to do for others
o Exercise maximum amount of control over own
life as possible
o Maintain religious and cultural practices
o Be respected as individuals
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Nursing Considerations for Mental Health
Conditions #4
 Managing behavioral problems
o Behavioral problems: actions that are annoying,
disruptive, harmful, generally deviate from the norm,
tend to be recurrent in nature (physical or verbal
abuse, resistance to care, repetitive actions, wandering,
restlessness, suspiciousness, inappropriate sexual
behavior and undressing)
o Occurs in persons with altered cognitive status who are
incapable of thinking rationally, making good
judgments, and coping
o Contributors to problem: illness that lowers ability to
cope with change or stress, medications, environmental
factors, loss of independence, insufficient activity
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Nursing Considerations for Mental Health
Conditions #5
Managing behavioral problems (cont.)
o First step is assessing the cause of the behavior
o Document factors associated with behavior:
 Time of onset; where it occurred;
environmental conditions; persons present;
activities that preceded; pattern of behavior;
signs and symptoms present; outcome;
measures that helped or worsened behavior
o Correct underlying cause of problem
o Avoid factors that precipitate behavioral problem
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Nursing Considerations for Mental Health
Conditions #6
Managing behavioral problems (cont.)
o Identify signs/symptoms that precipitate the
behaviors
o Intervene in a timely manner
o Environmental considerations
o Correct the underlying cause when possible
o See Table 27-3
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