The healthcare worker is faced with a complicated decision matrix when it comes to addressing the older adult’s driving privilege; there are personal, clinical, ethical, and legal ramifications. The healthcare worker is often consulted about the safety of the older adult who drives and is faced with the weight of the older adult’s needs and safety versus the safety of society. The healthcare worker is encouraged to refer to state laws associated with reporting of unsafe driving and prescribed revocation of driving privileges in addition to the information provided. Social support system (Isolation) An important part of the social history is the social connectedness of the older adult. The older adult is capable of being physically and mentally healthy and maintaining autonomy. However, the inescapability of mortality often pushes the older adult living away from friends, family, and possibly their partner. An increased sense of isolation can cause symptoms of depression (Sadock et al., 2015). The healthcare worker can assess the social support system the older adult utilizes on a daily/weekly/as needed basis to better understand any deficits of care in the social history section of the psychiatric interview. Where the older adult resides is an important consideration for social support. The healthcare worker might work along with the long-term care facility team in coordinating the social needs of the older adult. Social isolation and loneliness have negative effects on the mental health for the older adult. They increase the risk for negative health consequences such as obesity and smoking as well as shorten life span (Czaja et al., 2021). The members of an older adult’s social cohort and family structure will vary. There are objective and subjective measurements for social isolation and loneliness. The number of contacts and size of a social support network can be quantified, whereas loneliness is subjective. Loneliness is verbalized by the client and assessed qualitatively. Older adults who live alone are not always lonely. Loneliness is multifaceted and often intertwined with social interactions, which are unique to each client. Assessing limitations such as revoked driving privileges that can alter social interactions requires the healthcare provider to assess the social domain. Social engagement (personal, community, society connection) and individual productivity are major keys of successful aging (Czaja et al., 2021). This requires the healthcare provider to assess the quality of interactions and feelings of belonging when evaluating quality of life of the older adult. Faamily history The family history of an older adult can provide a genetic understanding and hint at vulnerabilities. Formal diagnosis can be lacking in older generations; however, subjective data on family members is a worthwhile investigation for the healthcare provider. Some mental health diagnoses are more likely than others to run in families. Obtaining historical family mental health diagnoses and medical diagnoses can focus risks as well as treatment options for the healthcare provider to consider. The healthcare worker can obtain the family history from the older adult, the family of the older adult (with consent), or caregiver(s). Sexual orientation, function, and dysfunction Sexual identification and function are assessed regardless of age. Older adults who identify as part of a sexual or gender minority (lesbian, gay, bisexual, transgender, etc.) are more prone to sexual difficulties and psychological distress later in life (NIA, 2022a). The healthcare provider is cautioned to assess with open empathy. Older adults often redefine the meaning of sexuality and intimacy in their life, and the healthcare provider must approach sexuality professionally and at the comfort level of the older adult. The healthcare provider needs to assess for the importance of sexual performance in the older adult’s life. For example, sexual dysfunctions that can include decreased desire, delayed or absent orgasm and ejaculation are known side effects of antidepressant medications (Sadock et al., 2015). The healthcare provider must know the expected physical changes that occur in the older adult female, shortening and narrowing of the vaginal walls and decreased lubrication, which can decrease enjoyment of sexual activity (NIA, 2022a). The healthcare provider must also know the age-related physical changes that occur in the older adult male, erectile dysfunction (impotence)
and decreased firmness with erection, which can cause stress in the older adult (NIA, 2022a). The healthcare provider can assess for sexual dysfunction distress. There are other common causes of sexual dysfunction: alcohol in excess, arthritis, chronic pain causing exhaustion and decreased energy, dementia, depression, diabetes, heart disease, incontinence, obesity, and stroke (NIA, 2022a). The healthcare provider can prescribe or refer the older adult for evaluation and treatment if desired. Substance use, abuse, and treatment history Substance use and abuse are a crucial part of the psychiatric assessment for the older adult. The Substance Abuse and Mental Health Services Administration (SAMHSA) states that substance use and abuse in older adults is often “overlooked and undertreated” (SAMHSA, 2022d, p. xi). The healthcare provider is reminded to self-assess for ageism, conscious bias, and unconscious bias that might inhibit the ability to evaluate substance disorders in the older adult. Substance use disorder (SUD) guidance for the older adult population includes the following (SAMHSA, 2022d): ● Substance misuse disorders occur more in younger populations than elderly populations; however, this does not void the importance for assessment. ● Substance misuse in older adults increases physical injury and mortality. ● Illicit drug use in the older adult population is currently on the rise, as is dual diagnosis (co-occurring mental health and substance use disorders). ● Alcohol is the most abused substance by older adults. ● Caution is warranted for the older adult due to the commonality of multiple prescriptions and possible detrimental interactions with substances. ● Substance abuse symptoms can mimic cognitive deficits (normal or clinical). ● Avoid assumptions that older adults are unwilling to change or seek treatment. ● Multiple approaches have been found to be effective in the older adult population (screening, brief intervention, and referral to treatment; brief structured treatment; patient education; relapse prevention techniques; formal SUD treatment programs; and pharmacotherapy). With alcohol being the most commonly misused substance by older adults, the healthcare worker must understand the risk factors contributing to increased alcohol consumption by the older adult. Older adults will experience numerous life stressors such as financial hardship, retirement or involuntary loss of job, living rearrangement, loss/grief/bereavement, trauma, or social isolation (SAMHSA, 2022d). Increased alcohol use and misuse can be detrimental to the older adult. Due to aging factors such as decreased metabolism and body fat storage, the older adult is more at risk for confusion, falls, injury, and exacerbated chronic conditions (SAMHSA, 2022d). The healthcare provider should assess tobacco product use presently or historically. Older adults who are lonely are at greater risk for smoking (Czaja et al., 2021). Smoking, vaping, or oral tobacco habits can be noted and assessed for intervention. Assessment of substance (legal or illegal), quantity, and frequency of use is critical for accurate assessment. Barriers to older adults seeking treatment for substance misuse include the following (SAMHSA, 2022d): ● Negative beliefs and attitudes. ● Denial. ● Justification (caregivers accepting misuse due to the end of life). ● Decreased information on dangerous effects of substances and older age. ● False information about older adult treatment. Protective factors for the older adult against substance misuse include the following (SAMHSA, 2022d): ● Healthy coping skills. ● Marriage or committed relationships. ● Social and family support.
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