healthcare worker can use a self-reporting scale when assessing. Geriatric-specific depression scales are available, but documenta - tion and scope of practice should be discussed with your place of employment. A strength assessment can help the healthcare worker find the older adult’s historical methods of coping and re - silience. It can also highlight unhealthy coping mechanisms that can be discussed. Questions for assessing an older adult’s strength include the fol- lowing (Boyd, 2017): ● How have you coped with depression or depressive symp- toms in the past? ● What do you find relaxing? ● What brings you joy? Treatments and recommendations for depression depend on the health status of the older adult and their living situation. Treat- ment may be necessary for older adults experiencing symptoms of depression that have a sustained impact on positive mental health: physical exertion, proper nutritional intake, regular restful sleep, social connection, and engagement in activities that bring satisfaction (NIA, 2021b). These recommendations can be individ- ualized to fit the needs of the older adult and their circumstances. Suicidal risk The older adult population has a particularly high rate of suicide. White men over the age of 65 have a risk that is five times higher than the general population, and older adult men account for 60% of all completed suicides (Sadock et al., 2015). The safety of the older adult is paramount for all healthcare workers in all settings. The recognition of risk factors coupled with appropriate interven- tion can save lives. Risk factors can be modifiable or nonmodifi - able. The APA clinical practice guideline (2010) notes genetics, family history, and demographics as nonmodifiable risk factors. Knowing the older adult’s risk factors can aid the healthcare worker in risk calculation but does not precisely predict attempts. The National Council on Aging (NCA) (2021) notes loneliness as the top reason for suicidal ideations, followed by suicidal intent caused by feelings of deep grief over a loved one, mourning the loss of autonomy and self-sufficiency, chronic illness and pain that decrease the quality of life, cognitive impairment and demen- tias, and financial stress that causes an inability to pay bills. The older adult’s increased suicide risk is also consistent with a men- tal health diagnosis of depression, schizophrenia, posttraumatic stress disorder, substance use disorders, an inclusion of trauma, an experience of discrimination based on sexual identity, access to lethal means, and sleep disturbances (LeFevre & Force, 2014). The suicidal older adult with access to lethal means should trig- ger the healthcare worker to immediately assess for safety. Sta- tistics show that older adults plan more thoroughly for suicidal completion and are most likely to use lethal means (firearms) than younger populations (NCA, 2021). Reasons stopping or prevent- ing the older adult from following through on suicidal thoughts, Anxiety Anxiety is commonly found in early or middle adulthood but can be seen after 60 years of age, although initial panic disorders are very rare (Sadock et al., 2015). The symptom profile for older adults experiencing anxiety is different than younger populations. Older adults tend to be less symptomatic, yet they are equally as troubled. The decreased symptoms have been attributed to a decreased autonomic nervous system (Sadock et al., 2015). Older adults have a vast life experience that can include change, transi- tion, loss, and death. Upon assessment, loss, grief, and bereave- ment can look like anxiety. When assessing anxiety, it’s necessary to establish the underlying etiology, length of symptom interfer- ence, and cultural considerations. A thorough psychiatric history is needed for clarity of diagnosis. Degrees of clinical anxiety are mild, moderate, severe, and panic (Boyd, 2017). Anxiety often ac- companies depression. The older adult with depression is at a higher risk for suicide; therefore, anxiety symptoms coupled with depression need a critical safety assessment (Sadock et al., 2015). There are medical conditions that can mimic anxiety symptoms in the elderly. Further assessment is needed to rule out stroke, multiple sclerosis, cardiac dysfunction, irritable bowel syndrome,
Case management and community engagement can be useful additions for support. The APA has published treatment recommendations specific to age ranges. For initial treatment of the older adult with MDD, the APA (2019) recommends group-based cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) in combina- tion with pharmacotherapy. The APA recognizes that treatment options are dependent on social determinants. The following are recommended treatments for MDD if group CBT or IPT are un- available for initial treatment: individual CBT with or without phar- macotherapy and problem-solving group therapy (APA, 2019). If the healthcare provider is considering psychopharmacological interventions, a review of the AGS list of potentially unsafe medi- cations for the older adults is needed. The AGS (2019) lists two tricyclic antidepressants, amitriptyline (Elavil) and imipramine (To- franil), as potentially inappropriate and encourages considering prescribing selective serotonin reuptake inhibitors (SSRIs) citalo- pram (Celexa) and sertraline (Zoloft) as well as bupropion (Well- butrin) if possible. Treating depressive symptoms of MDD with medication can be accomplished but must be reviewed for the safest option that meets the needs of the older adult. intent, and plans are called protective factors. Protective factors that apply to the older adult are cultural views, spiritual beliefs, coping skills, personality traits, social support systems, and past responses to stress/loss/bereavement (APA, 2010). Assessment can be completed during the psychiatric interview. The healthcare worker can use an informal format or systematic questioning to elicit safety responses. No formal training is needed to administer the brief suicide screener called the Columbia Suicide Severity Rating Scale (C-SSRS) (SAMHSA, 2022a). All healthcare workers can administer the C-SSRS. The tool probes the older adult about their intent, plan, and preparation for death. If the questions are answered honestly, it can indicate older adults who are at high risk of suicide completion (The Columbia Lighthouse Project, 2016). To garner the greatest gains, the healthcare worker must utilize empathy to nurture an environment of trust within the therapeutic alliance with the older adult during this part of the assessment. The APA (2010) recognizes the use of a suicide contract com- monly called a no harm contract between a mental healthcare provider and a patient. There is no evidence to prove its effective- ness in prevention and it is cautioned against as a replacement for a thorough suicide risk assessment. But it can be a useful method for discussing protective factors and a safety plan of action. The healthcare worker has decisions to make based on the level of risk verbalized by the older adult. The approach for intervention will depend on the severity of risk, workplace policy, and state legali- ties—especially related to breaching confidentiality. The health - care worker will abide by the individualized plan of action for sui- cide prevention according to protocol and treatment setting. hypoglycemia, hyperthyroidism, hepatic failure, vitamin B defi - ciencies (1, 6, and 12), and decreased folic acid (Subramanyam et al., 2018). Laboratory studies can also confirm the presence of interference when considering the diagnosis of anxiety. If anxi- ety is found in the older adult, assessment for substance use and abuse is needed. Alcohol is often the drug of choice to self-med- icate anxiety, but it is an inappropriate and ineffective method for anxiety treatment (Boyd, 2017). Treatment can be tailored to the individual needs of each patient. The AGS (2019) provides a list of potentially inappropriate medications for older adults, and it includes the benzodiazepines alprazolam (Xanax), lorazepam (Ativan), and diazepam (Valium) and offers alternatives for medi- cating anxiety with buspirone (Buspar) and SSRIs like citalopram (Celexa) and sertraline (Zoloft). Nonpharmacological approach- es are plentiful for the treatment of anxiety in the older adult. The clinical practice guideline for geriatric anxiety recommends nonpharmacological methods of treatment: lifestyle modifica - tions (sleep, diet, exercise, social support), behavioral therapy (relaxation), cognitive-behavioral therapy, mindfulness, yoga, art/ dance/music therapy, or alternative therapies (Subramanyam et al., 2018). Knowing how the older adult has coped in the past is
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