less (Boyd, 2017). The healthcare worker will assess safety and the social support network to help the older adult overcome com- plicated grief. Grief that does not follow a normal response in the timing of symptoms can be documented as delayed grief. In delayed grief, there is a lack of initial symptoms of grief but they surface later (Sadock et al., 2015). The healthcare worker can explore the Kübler-Ross cycle of grief to assess for extended de- nial when the older adult appears stoic in presentation to acute loss. Cultural norms and awareness are cautioned as the health- care provider works with the client to determine their definition of normal and what an appropriate response to loss and death are. Another form of grief is prolonged grief, which is sometimes called traumatic grief because the loss was unforeseen. It is simi- lar to persistent complex bereavement disorder. Persistent com- plex bereavement disorder is a clinical diagnosis that requires the deceased to have a significant connection to the mourner. In addition, there are intense feelings of yearning/sorrow/constant thoughts of the deceased/constant thoughts of the nature of death (one of those), and these difficulties interfere with function - ing for more than a year after the death (APA, 2013). Traumatic grief is more difficult to cope with, thus leading to a longer recov - ery time. It often includes external circumstances such as violence, abruptness, and unanticipated or preventable death (Boyd, 2017). Traumatic grief is often termed prolonged grief due to extenuat- ing forces and an anticipated loss. Therefore, the person experi- encing the loss faces a longer period of change and adaptation. Case study: Ms. P Ms. P. is a 68-year-old Caucasian female being seen by you in the mental health clinic. She recently lost her husband of 48 years. She barely talked at her appointment last week and has mostly been looking down at the floor avoiding eye contact. She reluc - tantly tells you that she overheard her children talking about hous- ing options for her. She does not want to leave her home. Her husband drove her to all of her appointments and took care of all of her needs (groceries, medications, etc.). She has two married children who both live out of state. Her oldest daughter brought her to the visit today and is sitting in the lobby. Ms. P has a history of colon cancer (currently in remission), diabetes, hypertension, and depression. She takes oral medication for her elevated blood pressure, diabetes, and depression. Today she tells you that she feels empty, alone, and hopeless. Neurocognitive disorders Changes in cognition are statistically significant for the older adult population (Boyd, 2017). The healthcare worker must understand the differences in neurocognitive disorders for assessment, in- tervention, treatment, and when to refer to other disciplines and community resources. According to the APA (2013), the DSM-5 diagnosis of a neurocognitive disorder is a deficiency in the fol - lowing: attention (distractibility with multiple stimuli), executive functioning (decision making, planning, and working memory), Delirium Delirium is a neurocognitive disorder that a healthcare worker will come across in the older adult population. Delirium is an acute cognitive impairment caused by an underlying medical culprit (Boyd, 2017). The healthcare worker needs sharp attention of its presence; however, treatment is often administered in the acute care setting by medical professionals. There are a multitude of risk factors and known causes for delirium in the older adult popula- tion. Delirium risk factors for the older adult include the following (Boyd, 2017): ● Advanced age (65 years and older). ● Male. ● History of falls. ● Preexisting dementia.
Symptoms of traumatic grief/prolonged grief include the follow- ing (APA, 2013): ● Last all day (nearly every day) for at least one month. ● Disruption of self (feeling loss of self). ● Extended denial about the death. ● Inability to confront reminders of the deceased person (avoid- ance). ● Intense outward feelings (emotions such as anger). ● Constant struggle with moving forward with daily activities and social engagements. ● Empty feelings about life. ● Loneliness (feeling isolated and distant from others). While considering the cycle of grief and the various types of grief an older adult may experience, the healthcare worker should con- sider the symptoms of grief and their interference with function- ing and relationships, the risk of self-harm or harm to others, and the symptoms of clinical depression when presenting appropri- ate intervention. Most grief will resolve on its own accord without psychiatric intervention; however, a healthcare provider might be consulted for acute medical intervention. Sleep deficits can be ad - dressed with short-term psychopharmacological agents; however, anxiolytics, antidepressants, and narcotics are not recommended for normal grief (Sadock et al., 2015). If therapy is warranted, the healthcare worker can provide options for treatment. Grief therapy (one-on-one or group sessions) and self-help groups have been found to be most beneficial for those mourning and unable to overcome grief, loss, or bereavement (Sadock et al., 2015). The healthcare worker can work with the client, family, and community to assess the availability of resources to support the older adult. Question: What stage of grief is Ms. P in and what assessment criteria sup- ports this? Discussion: Ms. P is displaying signs that support the depression stage (Kübler-Ross & Kessler, 2005). She is stating that she feels empty, alone, and hopeless after the loss of her husband and loss of ac- cess to groceries, medications, and medical appointments. She is expressing concern that she might even be moved from her home. Depression is also a clinical diagnosis. Further assessment would be warranted to determine her safety risk and the need to intervene or treat. Ms. P’s daughter is in the waiting area and can possibly provide clarity and insight into Ms. P’s current and future mental health needs. learning and memory (recollection and recognition), language (expressive, fluency, grammar, receptive), perceptual-motor (vi - sual and motor perception), and social cognition deficits (emotion recognition, ability to relate to another). Differentiating cognitive regression and disruption can be difficult, especially when a base - line of functioning or collateral information is not available. The healthcare worker who assesses and/or treats older adults will en- counter older adults with neurocognitive disorders. ● Functional dependence (long-term care facility residents). ● Endocrine and metabolic disorders. ● Fractures in bones. ● Medications (consider AGS 2019 BEERS criteria for potentially inappropriate medications in older adults). ● Vital sign changes (hypotension, hypo- or hyperthermic). ● Imbalances in intake (dehydration, renal failure, hyponatre- mia). ● Long-term care admission. ● Pain (acute or chronic). ● Stress (acute or chronic, notable risk during loss or bereave- ment). ● Substance use and alcohol withdrawal (alcohol is greatest of- fense).
MENTAL HEALTH DIAGNOSES FOR THE OLDER ADULT
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