Mental Illness in the Elderly CNA Specialty Course Capital Community College Spring 2008 Dr. Linda A. Barile

Mental Illness in the ElderlyCNA Specialty Course

Capital Community CollegeSpring 2008

Dr. Linda A. Barile

Overview of Mental Illness

Class 1

Anxiety Disorder (Neurotic)

Generalized Anxiety Disorder Obsessive Compulsive Disease Phobia Panic Disorder Depression – Exogenous PTSD

Anxiety Disorder (Neurotic)

Judgment – Good Orientation – Good Memory – Good Affect – Anxiety, Depression Cognitions – Reality based

Personality Disorders

Borderline Antisocial


Judgment – poor, mistakes over & over

Orientation – good Memory – good Affect – Anger Anxiety & Depression Underlying Cognitions – may have brief

Psychotic episodes


(ANTISOCIAL) (DSMIV)a. Inability to delay gratification b. Inability to conform to norms of

societyc. Seeks pleasure


(ANTISOCIAL) (DSMIV)d. Lacks satisfying, fulfilling,

interpersonal relationships - egocentric

e. Lacks capacity for concern over others

f. Does not feel guilt, no conscience, remorse or shame


(ANTISOCIAL) (DSMIV)g. Impulsive-irresponsible-

rebellious-insincere-lyingh. Charmingi. Does not learn from mistakes-

unable to handle criticism


(ANTISOCIAL) (DSMIV)j. Impaired judgment and repeated

failuresk. Irritability, aggressivenessl. Denial, rationalization, projection

as defenses


(BORDERLINE) (DSMIV)a. Identity disturbanceb. Physically self-damaging actsc. Unstable affect


(BORDERLINE) (DSMIV)d. Chronic feeling of emptiness /

boredome. Lack of tolerance for being alonef. Intense, unstable relationships


(BORDERLINE) (DSMIV)g. Impulsivity, unpredictabilityh. Inappropriate or intense anger

Psychotic(Hallucinations, Delusions, Bizarre Behavior)

Schizophrenia Bipolar Depression – Endogenous, Comes

from within Family History

Psychotic(Hallucinations, Delusions, Bizarre Behavior) Judgment – poor Orientation – may not be affected Memory – unremarkable Affect Schizophrenia – flat Bipolar – Manic or Depressed Depression – sad Cognitions – Hallucinations, Delusions

Organic

Dementia Chronic No known cause Irreversible Example - Alzheimer's

Organic

Delirium Acute Know cause Reversible Example - DT’s

Organic

Judgment – poor Orientation – poor Memory – poor for recent events Affect – Labile Cognitions –

Hallucinations/Delusions

Special Category

Anorexia/Bulimia Addiction Abuse

Levels of Anxiety Mild Moderate

Ability1) Attend2) Listen3) Concentrate4) Learn

Levels of Anxiety Severe Panic

Ability1) Cannot function2) Can’t problem solve, make

decision, choice etc.

Obsessive/Compulsive

a. Obsessive: painful idea, recurrent, persistent thoughts

b. Compulsive: behavior or acts i.e. repetitive, ritualistic physical acts

c. Disproportionate degree of anxiety

d. Repression of conflict

Obsessive/Compulsivee. Knows thoughts and behavior

is senseless but cannot control it- Interferes with functioning

f.Has conflict and guiltg. Behavior relieves tensionh. Dependency, self-defeating

behavior, low self esteem, inadequacy, inferiority

Obsessive/Compulsive

i. Inability to make decisions based on anxiety about failure - ambivalence -strives for perfection

j. Defense mechanisms:Obsessive - reaction formation,

displacementCompulsive - undoingk. Depression may be underlying

Overview of Mental Illness

Class 2

Phobias

a. Anxiety is bound up in fear of a particular object or situation - Avoid dreaded object

b. Feared object symbolizes underlying conflict

c. Fear is not subject to conscious control

Phobias

d. Defense mechanism of displacement

e. Fear is recognized as unreasonable but has a major effect on the person's life

f. May be a learned behavior

Powerlessness Related To Depression

Theories of Depression Biological – serotonin deficiency Psychological

Aggression turned inward Crisis: precipitating event, perception, coping,

supports Cognitive: depressive thoughts cause

depression feelings and behavior Learned helplessness: same symptoms of

depression Sociological: family and society


a. Affect or Mood1.Hopeless, helpless, discouraged2.Inability to experience pleasure3.Negative feelings about self (guilt, low

self-esteem), others, and the world 4.Anxiety, agitation, anger turned inward

(psychomotor agitation/retardation), monosyllabic speech


b. Thoughts1. Slow, worried, preoccupied

thoughts (psychomotor retardation) 2. Unable to make decisions 3. Concern with physical health 4. Possible hallucinations, delusions if

psychotic5. Thoughts of death or suicide


c. Behavior1. Passivity dependence2. Social isolation; lacks initiative


d. Physical Problems1. Loss of appetite, insomnia or

excessive sleeping, constipation, loss of sex drive


e. Basic problem - inability to express anger (defense: introjections - anger turned inward).

If anger or hostility is expressed before client is able, he will feel increasing guilt and possibly be suicidal.

Suicide

a. Depression, low self esteemb. Hopelessness, Helplessc. Guiltd. Ambivalence

Suicide

e. Anger turned inward (introjection)- Help patient deal with anger in constructive manner

f. High in men, 50 years and older, with high stress such as divorce or loss of job and

g. Specific plan. Suicide is one of the leading causes of death in adolescents and the elderly

Bipolar (Manic Phase)

Emotional manifestation (affect or mood)1. Elated, euphoric, hyperirritability2. Happy, playful3. Grandiose

Bipolar

Cognitive manifestations (thought processes)1. Rapid and pressured2. Positive3. Hypercritical and blames others4. Flight of ideas

Bipolar

Behavioral Manifestations1. Domineering2. Wants independence - dislikes

restrictions or restraints

Bipolar

Physical manifestations1. Hyperactivity2. Not easily fatigued3. Appetite is variable4. Hypersexual5. Insomnia6. Impairment of personal hygiene

Schizophrenia

Signs and Symptoms

Affect or Mooda. Severe or panic anxietyb. Sensitive to feelings of othersc. Flat or inappropriate Affectd. Ambivalence

e. Low self-esteem, insecurity

Schizophrenia

Signs and Symptoms

Thoughts or Cognitiona. Thought disorderb. Lack of trustc. Lack of sense of self - Lack of ego

structured. Autism- disordered communication-

extreme withdrawal into non-reality

Schizophrenia

Signs and Symptoms

Thoughts or Cognitione. Loose Associationsf. Hallucinations/delusions, ideas of

referenceg. Neologism, word salad, echolalia

Schizophrenia

Signs and Symptoms

Behaviora. Isolation from others, withdrawalb. Introversionc. Disturbance in previous level of

functioning or goal directed behaviord. Disturbance in body image and self-

concept

Schizophrenia

Signs and Symptoms

Symptoms of SchizophreniaPositive Symptoms a. Hallucinations b. Delusionsc. Bizarre behavior

d. Loose associations

Schizophrenia

Signs and Symptoms

Symptoms of SchizophreniaNegative Symptoms - of depression a. Slowed thoughtb. Diminished spontaneityc. Flat affect - loss of drived. Apathy

Schizophrenia

Signs and symptoms

Symptoms of SchizophreniaNegative Symptoms - of depression a. Attention concentration difficultyb. Few wordsc. Withdrawal

d. Not able to experience pleasure

Addiction Basic Problem Physical and psychological addiction with

tolerance and or withdrawal Withdrawal from alcohol 8-24 hrs-anxiety, nervousness, irritability,

upset stomach 12-48 hrs-agitation, temp 100 or above, pulse

100 or above, BP> Alcoholic hallucinations (well lighted room to

prevent shadows) 3-5 days-convulsions, coma, death

Addiction

Heroin withdrawal-every bone in body aches, vomiting, dilated pupils, diarrhea

Cocaine-when on Cocaine looks like bipolar in manic stage-withdrawal is depression

Dynamics of Anger

Class 3

Dynamics of Anger Analyze the dynamics of anger and

hostilityTopics

Recognize one’s own response to anger and hostility

Dynamics of anger and hostility Role of anger in depression, suicide

Dynamics of Anger

Identify theories and precipitating factors to

anger and conflict situations TopicsTheories of Anger: Biological Psychological Social, cultural and spiritualPrecipitating factors Threats Loss Unmet expectations

Dynamics of Anger

Discuss anger management and stress management

Topics Anger Management Bodily skills Mental skills Thinking skills Empathy training Explanatory Style

1. Thoughts, feelings, behaviors2. Commitment, challenge and control3. Optimism vs. pessimism

Stress cycle and breaking the cycle

Dealing withDifficult Behaviors

Class 4

Hallucinations

Identify strategies to deal withhallucinations

Strategies Relaxation or meditation Keep a record of when you hear the voices –

date, time place Talk to others, talk on the phone, write a letter

–don’t have to talk about your voices Use Aversion Self Therapy-snap a rubber band,

imagine something unpleasant Tell the so called voices to go away – dismiss

them

Hallucinations

Take care of your physical health-eating, sleeping, vitamins, exercise

Tune out the voices Use music, television etc. Use

headphones Avoid alcohol or illegal drugs, over the

counter drugs and caffeine Talk to yourself – view your voices as

your own thoughts

Hallucinations

Challenge what the voices are telling you Use thought stopping and tell the voices to

stop-then think of something pleasant Use time out if being with others make the

voices worse Use earplugs in one ear Use positive self-talk Use distraction-housework, gardening, sports

event, reading, change your environment Use your own voice – humming, singing,

counting, positive mantra, reading out load

Hallucinations

Role Play dealing with difficult behaviors

Caregiver Interventions

Hallucinations/Delusions1. Do not argue, challenge or reason. Do not taste food if

patient thinks it is poison. Do not indicate non-verbal agreement.

2. Delusions are defenses against underlying feelings, themes and needs. Delusions reflect sense of vulnerability. Meet the need the delusion serves.

3. Make empathic comments-"It must be frightening"-address feelings and content.

4. State simply that you do not hear voices. Ask what the "so called" voices or "voices you say you hear" are saying.

5. Provide distraction or competition for voices while actively hallucinating.

6. Provide extra support and stay with patient (use supportive approach with schizophrenia).

7. Ask what the so-called voices were saying - do not question at great length giving status to voices.

STRESS MANAGEMENT

Class 5

Stress Cycle

Event

Thoughts

Perception

Positive CopingVisualization

Fight, Flight,Freeze

Relaxation

Anger CycleThreatLoss

ChangeUnmet

Expectations

Helpless/Powerless

Anxiety

AngerDepressionSomaticizi

ngCompromis

e

Justification

6 Determinants as to Whether You Will Feel Stress

Control Challenge Commitment Powerlessness Choices Ownership

Home &

Family

Work&

Money

Health&

SanityFun

Spirituality

Values

Communication

Class 6

Communication

Models of Interpersonal Behavior

Communication model – Communication is the process by which information is exchanged between two or more persons.

Transactional model – the study of the communication or transactions that take place between people and of the sometimes unconscious and destructive ways (games) that people relate to each other.

Communication

Models of Interpersonal Behavior

Human needs – emphasizes that all humans have the same basic needs and that these needs are what motivate a person’s behavior. Maslow described five basic categories of needs: physiological, safety, love and belonging esteem needs, and self-actualization.

Values model – values are important because like needs they affect interpersonal behavior. Values of health care professionals might be as follows: helping others, independence, equality, authority etc.

Communication

Interpersonal Communication Skills

Empathy – Ability to sense the other person's world as if it were your own

Respect – a feeling of high regard, honor or esteem for another person

Genuineness- authentic, honest, true, forthright, Immediacy – dealing with the here and now Concreteness – the what, when, where, how but not

why. The ability to be specific Confrontation – pointing out discrepancies between

thoughts, feelings and behaviors. The act of presenting differing observations. Sharing that behaviors are discrepant is an act of confrontation.

Assertion

Empathy

Definition: Ability to sense the other person's world as if it were your own. Aware of the other person's feelings and reflect understanding back to the person. (e.g. "You feel _____ because.")

Skills Necessary Attending - Offering Self Listening – Silence Observing - Non-Verbal Responding - Reflecting

Respect (warmth, non-judgmental)

Positive Regard Definition: Accepting another without

conditions or judgments - caring for the person and believing in his ability

Blocks to Respecta. False Reassurance b. Agreeing/Disagreeing c. Giving Advice or Opinion d. Challenginge. Defending

Concreteness Restating technique, seeking clarification,

genuineness a.Questioning - who, what, where, SELDOM WHYb. Open vs. closed questioning (open is

preferable)c. Double questions - to be avoidedd. Bombarding questions - to be avoided

Summarizing Technique Confrontation - giving immediate feedback

Priorities in Limit Setting

Destructive Disorganized Deviant Withdrawn Dependent Behaviors

Reality Orientation

Definition: Techniques for providing basic, current information to a person having memory loss, confusion, and time-place disorientation

Documents

Mental Illness in the Elderly CNA Specialty Course Capital Community College Spring 2008 Dr. Linda A. Barile