The Elderly and Understanding
Difficult Behaviors
Chinita Manbeck, LMSW
Introduction
• The elderly population in the United States is exploding. As
the number of individuals in this age bracket steadily
increases, the elderly are quickly becoming frontrunners for
those needing assistance and attention.
• When an individual is labeled as “elderly” or “old”, these
labels reposition that person from a normal position in society
to a different role. The media plays a prominent role in
labeling “old” as something to be ashamed of; the majority of
products advertised are to reverse signs of aging.
• Myths and distorted views about aging encourage
stereotyping, which results in treating the elderly in ways that
are detrimental to their self-esteem, independence, mental
and physical health. In addition, the elderly may begin to
believe these fabrications and integrate them in their thought
process and behavior.
Introduction cont.
• Older adults prefer to reside in their own home but tend
to choose assisted living facilities as an alternative in an
effort to maintain their autonomy and self-respect at the
same time obtaining assistance with their ADLs.
• The many challenges in social service delivery for
assisted living facilities are similar to those seen in a
majority of continuing care communities (retirement
communities, long-term care facilities, skilled nursing
facilities). There are several limitations to these
communities and their surrounding environment,
including the high financial burden, dependency issues,
and how time consuming it can to be to care for an aging
person.
Demographics
• The population 65 and over will increase from 35 million in
2000 to 40 million in 2010 (a 15% increase) and then to 55
million in 2020 (a 36% increase for that decade).
• The 85+ population is projected to increase from 4.2 million
in 2000 to 5.7 million in 2010 (a 36% increase) and then to
6.6 million in 2020 (a 15% increase for that decade).
• Over one in every eight, or 12.9%, of the population is an older
American.
• Persons reaching age 65 have an average life expectancy of an
additional 18.6 years (19.9 years for females and 17.2 years for
males).
• Older women outnumber older men at 22.7 million
older women to 16.8 million older men.
Demographics cont.
• About 30.1% of all older persons in 2009 lived alone
(8.3 million women, 3.0 million men). The proportion
living alone increases with advanced age. Among women
aged 75 and over, for example, half (49%) lived alone.
• 1.6 million of the 65+ population in 2009 lived in
institutional settings such as nursing homes.
• However, the percentage increases dramatically with
age, 0.9% for 65-74 years to 3.5% for 75-84 years and
14.3% for 85+.
• In addition, approximately 2.4% of the elderly lived in
assisted living with at least one supportive service
available to their residents.
Overview of Alzheimer's Disease and
Dementia
• About 3.4 million people, or 13.9 percent of the population
age 71 and older, have some form of dementia. As expected,
the prevalence of dementia increased dramatically with age,
from five percent of those aged 71 to 79 to 37.4 percent of
those age 90 and older.
• About 2.4 million of those with dementia, or 9.7 percent of the
population age 71 and older, were found to have Alzheimer's
disease, the most common cause of dementia.
• 75% of Long Term Care patients/residents have some form of
dementia.
• Most common disease with dementia symptoms is
Alzheimer's, it is the sixth leading cause of death in the U.S.
(2008).
Dementia
• Dementia means loss, there for it is a decline
from the previous level of functioning.
• Describes a group of symptoms and is not the
name of the disease.
• Loss of abilities in memory, behavior, social
skills, language, sensory perception and muscle
control.
Types of Dementia
• Types of dementia• Reversible; depression, substance abuse,
infections, head trauma, B 12 or thyroid
deficiency
• Irreversible; Alzheimer's, Parkinson's,
Vascular Dementia, Lewy Body, Frontal
Lobe Damage
Alzheimer's Disease
• Autopsy is the only way for a definitive diagnosis
of Alzheimer’s
• 95% accuracy through:
• PET scan
• Cognitive status exams
• Neurological examination
• Lab test (beta-amyloid levels)
Alzheimer’s affects a person’s ability
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Understand our reality; live in their reality
Understand language:
Word loss, can’t find words vocabulary shrinks
Organize thoughts and ideas into words
Revert to former language
Speak
See the world as it is
Visual impairments
Hallucinations
Shadows
Hear the world as it is
Sound location
distortion
Behaviors and Symptoms
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Wandering
Pacing
Confusion
Sleeping
Rummaging/hoarding
Want to go home
Want’s Mom
Socially inappropriate
Sexually inappropriate
Loss of ADL function
Delusions
Hallucination
Communication loss
Anxiety
Aggression
Sundowning
Mental Illness/Disorders
• Mental illness/disorder is a term that describes a
broad range of mental and emotional conditions.
• DSM-IV defines it as a collection of
symptoms, behavioral or psychological
that causes an individual distress,
disability, or the increased risk of
suffering pain, disability, death or the
loss of freedom.
Most common forms of mental
illness/disorders
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Depression
Bipolar Disorder (Manic-Depressive)
Anxiety Disorders
Panic Disorders
Obsessive Compulsive Disorders
Personality Disorders
Schizophrenia
Treating mental illness/disorders
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Symptoms can often be controlled effectively by:
Behavior management
Psychotherapy
Medication
Symptoms may even go into remission but
illness can continue to cause periodic episodes
that require treatment.
Neurosis / Psychosis
• Neurosis; grounded in reality but
thinking/behaving are dysfunctional
• Depression
• Bipolar Disorder
• Personality Disorders
• Psychosis; cannot differentiate between what is
real and imaginary (often episodic)
• Schizophrenia
• Bipolar Disorder
Depression in Older Adults
• Older depressed individuals often have severe
feelings of sadness and loss, but these feelings
are not acknowledged or openly shown.
• Thinking that depression is an inevitable sign of
aging, many people ignore or deny their
symptoms.
• Highest rate of suicide is in the over 65
years of age group. One suicide every 90
minutes.
Symptoms of Depression in the Older
Adult
• Memory problems
• Confusion
• Social withdrawal
• Loss of appetite
• Sleeplessness
• Irritability
• Delusions and hallucinations
• Chronic Pain and or medical complaints
Unaddressed depression in the older adult is too often
assumed to be an untreatable form of dementia.
Memory loss is not a normal part of aging.
Bipolar Disorder (Manic Depressive)
• Mood disorder involving episodes of serious
mania and depression.
• Multiple types exist with varying degrees of
mania and depression.
• Usually begins in adolescence or early adulthood
and continues throughout life.
Criteria for Depressive and Manic
Episode
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Sad mood lasting more than two weeks
Lost of interest
Weight loss or gain
Excessive sleeping or extreme lack of sleep
Reduced psychomotor activity
Fatigue
Loss of sense of self worth
Lack of concentration
Thoughts of death
Manic Episode
Reduced need for sleep
Increased talkativeness
Easily distracted
Hyper psychomotor activity
Increased sex drive
Poor judgment
Psychotic feature
Impaired Grandiosity or exaggerated self esteem
Anxiety Disorders
• A feeling of dread or apprehension sufficient enough to
interfere with daily functioning
• Anxiety disorders can make a person avoid everyday,
routine functions altogether in an effort to curb the
stressful feelings they cause
• Signs any symptoms include inability to concentrate,
sleep disturbances, panic attacks, irritability, excessive
worry
• Physical symptoms; dry mouth, heart
palpitations, fatigue, muscle tension
• It is common for one anxiety disorder to coexist with
another disorder or several others (e.g. anxiety and
depression).
Panic Disorder-Phobias
• An anxiety disorder that exhibits instance of extreme
fear or discomfort
• Starts abruptly and builds to a rapid peak, usually within
ten minutes
• Usually accompanied by a sense of looming danger and
the strong desire to escape
• Brought on by specific phobias or triggers, or can occur
“out of the blue”
• Signs and symptoms include heart palpitations,
sweating, trembling, shortness of breath, the sensation
of choking, chest pain, nausea, dizziness, disorientation,
fear of losing control or dying, numbness, chills and hot
flushes
Obsessive Compulsive/Hoarding
The excessive collection and retention of things or
animals. An excessive attachment to items
collected and the inability to part with them.
Stems from the inability to make decisions or fear
of loss.
Elderly with dementia and Schizophrenia 700,000
to 1.4 million of them are hoarders.
Hoarding
Older adults hoard for the following reasons:
• Obtaining love not found from people
• Fear others will obtain their personal information
• Physical limitations and fragility
• Self neglect
• Stressful life event
• Delusional
• Excessive attachment to possessions
• Inability to discard items
• Organizational difficulty
• Perfectionism
• Difficulty permitting others to touch or move accumulated items
• Procrastination
• Trouble making decisions
• Difficulty managing daily tasks
• Limited or poor socialization skills
Personality Disorders
• Great difficulty interacting with other people
• Tendency to be inflexible, rigid, and unable to
respond to changes and life demands
• Often feel their behavior patterns are “normal or
“right”
• Tend to have a narrow view of the world and
find it difficult to participate in social activities
Continued…
• There are many formally identified personality
disorders, each with their own set of behavior and
symptoms. Many of these fall into three different
categories;
• Cluster A: Odd or eccentric behavior, e.g. Schizoid
Personality Disorder, Paranoid Personality Disorder
• Cluster B:Dramatic, emotional or erratic behavior;
e.g. Anti-social Personality Disorder, Borderline
Personality Disorder, Multiple Personality Disorder
• Cluster C:Anxious fearful behavior, e.g. Dependent
Personality Disorder, Avoidant Personality Disorder
Schizophrenia
• An organic brain disease linked to changes in the
brain chemistry and structure
• Impairs a person’s ability to think clearly, manage
his emotions, make decisions and relate to others
• For initial diagnosis must have two of the following:
Delusions, hallucinations, disorganized behavior,
disorganized speech and negative symptoms (flat or
blunted affect)
• 75% develop it between ages of 16 and 25
• Affects approximately 2% of the population in the
U.S.
Alcohol and Substance Abuse
• The elderly rarely use alcohol or drugs to “get high”;
drug or alcohol use that begins after age 60 appears
fundamentally different.
• The elderly turn to alcohol and drugs to alleviate the
physical and psychological pain from the onslaught of
medical and psychiatric illness, the loss of loved ones or
social isolation.
• Psychoactive drugs are all addicting and can impair
cognitive functioning, cause depression, increase the risk
of falling and interact dangerously with other
medications.
• Moreover, drug and alcohol abuse in older patients
occurs alongside other medical and psychiatric illnesses.
Alcohol and Substance Abuse cont.
• Numerous surveys document problematic drinking
among the elderly. For example, a 2011 National
Survey on Drug Use and Health found that 8.3
percent of adults 65 and older reported binge
drinking, defined as having four or five drinks on
one occasion in the past month.
• Although alcohol is clearly the most commonly
abused drug in the elderly, nonmedical use of
prescription drugs is a rapidly growing threat. Some
studies estimate that up to 10 percent of the elderly
misuse prescription drugs, most often Klonopin,
Ambien and opiate painkillers like Oxycodone.
Alcohol and Substance Abuse cont.
• Of the current population, 83% of older adults,
take prescription drugs. Older adult women
take an average of five prescription drugs
at a time, for longer periods of time, than
men. And studies show that half of those drugs
are potentially addictive substances, making
older females more vulnerable to potential
abuse. Women outnumber men when it comes to
nonmedical use of prescription medication: 44%
of women vs. 23% of men.
Alcohol and Substance Abuse cont.
• Various studies have shown that within the elderly
population:
• 19.1 % are at risk drinkers; 8.9% are heavy drinkers; 54.2% are
moderate drinkers
• 10.2% reported cocaine use
• 8.3% reported heroin use
• 21.1% prescription drug misuse/abuse
• 16% smoked tobacco
Screening for drug abuse in the elderly can be complicated.
Symptoms can be masked by normal or perceived signs of aging,
the elderly may deny symptoms of abuse, and may be unaware
of their misuse. The elderly do not fit the typical drug abuser
profile or stereotype and therefore awareness and services for
this population are lacking.
Treatment
Treatment may include psychopharmacology,
cognitive behavior therapy, reminiscence therapy,
behavior therapy, education, and increased social
support.
Cognitive therapy is an effective, directive, timelimited approach to helping people change their
irrational thoughts, assumptions, and beliefs.
Cognitive therapy and medications have been
more effective than either treatment alone.
Cognitive theory suggests that disorders arise from a
negative view of the world and from automatic and
negative thinking patterns (e.g., the future is bleak,
the world is bleak, and the self is worthless).
Treatment Cont.
• Extensive research shows that specific habitual
patterns of behavior and thinking are associated
with a number of mental disorders. The purpose
of CBT is to help the patient reduce or eliminate
the behavior and thinking patterns that are
contributing to his/her suffering and to replace
dysfunctional patterns of behavior and thought
with patterns that promote health and wellbeing.
Treatment Cont.
Reminiscence therapy is the process of recalling
personal experiences from an individual’s past.
The theory behind RT is that an individual’s
function is improved by decreasing demands on
impaired cognitive abilities; it is a way to affirm
who they are, what they’ve accomplished in their
lives, and a chance to relive happy times. For
those who suffer with dementia, depression or
anxiety it is a way to talk easily about things they
do remember.
Treatment Cont.
Behavioral therapy is a treatment that helps change
potentially self-destructing behaviors, also called
behavioral modification. This type of therapy is utilized to
replace bad habits with good ones and helps individuals
cope with difficult situations; most often used to treat
anxiety disorders. Most behaviorally oriented therapists
believe that the current environment is most important in
affecting the person’s present behavior, while early life
experiences and emotional/psychological conflicts are less
important.
Behavior therapy is generally intended to improve the
individual’s self-control by expanding coping skills,
abilities, and independence.
Discussion
• As the elderly population in the United States grows, the
number of individuals with behaviors will certainly increase
tremendously.
• Unfortunately, beliefs typically attributed to the elderly about
their mental health tend to be myths: elderly are assumed to
experience greater psychological problems; older adults are
thought to be plagued by sadness and loneliness; tormented
by fears of death and dying; families abandon their older
relatives and that the elderly almost always suffer from
dementia.
• With the growing geriatric population, greater attention
should be dedicated to the lives of seniors and toward
ensuring their physical, mental and emotional health as they
move toward later life; the elderly should not only be adding
years to their lives, but also life to their years.
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