● Alcohol is the most abused substance by older adults. ● Caution is warranted for the older adult due to the commonal- ity of multiple prescriptions and possible detrimental interac- tions with substances. ● Substance abuse symptoms can mimic cognitive deficits (nor - mal 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 re- ferral to treatment; brief structured treatment; patient educa- tion; 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 fac- tors 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 isola- tion (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 as- sess 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 as- sessed 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. ● Autonomy and independent living. ● Accountable basic needs covered (food, shelter, safety). ● Positive self-esteem and self-image. ● Access to medical care and medications. ● Sense of purpose and belonging. Person-centered care accounts for older age and lifestyle modi- fications, access to care, and quality of life considerations (SAM - HSA, 2022d). The healthcare provider needs to consider the fol- lowing for the older adult seeking treatment: physical disabilities to accommodate (mobility, hearing, vision), cognitive deficits that interfere (memory and attention), learning needs and preferences (slower pace and repeated information if needed), and respect for age and gender preferences for provider and group therapies. Spirituality The spiritual assessment of the older adult is documented in the social history section of the psychiatric evaluation. The healthcare worker is reminded that it is critical to maintain neutrality of stance while assessing the older adult’s spiritual beliefs. Spirituality is a broader topic than religion. It is estimated that 80% of Americans practice some type of religion (APA, 2013). All healthcare work- ers will interact with the spiritual aspects of an older adult’s be- liefs, religion, or purpose of life while meeting their mental health needs. The inability to address spiritual involvement in an older adult’s life can limit a client’s recovery (Neathery et al., 2020). If the healthcare worker is reluctant or uncomfortable assessing an older adult’s spirituality, a self-assessment to identify the barriers can be beneficial. Cultural awareness and acceptance are key for impartiality of assessment. Spirituality is a component of mental healthcare that is often woven into an older adult’s lifestyle, guid-
(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 con- nection) 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 un- derstanding 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 op- tions for the healthcare provider to consider. The healthcare work- er can obtain the family history from the older adult, the family of 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 sexual- ity 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 dys- functions 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 de- creased lubrication, which can decrease enjoyment of sexual ac- tivity (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, inconti- nence, 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 the older adult (with consent), or caregiver(s). Sexual orientation, function, and dysfunction Substance use and abuse are a crucial part of the psychiatric as- sessment 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 under- treated” (SAMHSA, 2022d, p. xi). The healthcare provider is re- minded 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 popula- tions 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).
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