GEROPSYCHIATRIC ASPECTS IN MENTAL HEALTH NURSING

1. GEROPSYCHIATRY
BY
ARUN M
KVM COLLEGE OF NURSING

2. GEROPSYCHIATRY
Geropsychiatry is a sub-speciality
of psychiatry dealing with mental
health and illness in the elderly.

3. Geriatric nursing
• Geriatric nursing is a specialty that concerns
itself with the provision of nursing services to
geriatric or aged individuals. (Basic Geriatric
Nursing- Mosby)

4. Terminologies used in Geriatrics
• Geriatrics
The term geriatric comes from the Greek words
“geras”, meaning old age, and “iatro”, meaning
related to medical treatment. Thus geriatrics is
the medical specialty that deals with the
physiology of aging and with the diagnosis and
treatment of diseases affecting the aged.

5. • Gerontology
The term gerontology comes from the Greek
words “gero”, meaning related to old age ,
“ology”, meaning the study of. Thus the
gerontology is the study of all aspects of the
ageing process, including clinical,
psychological, economic, and sociologic
problems of older adults and the
consequences of these problems for older
adults and society.

6. • Gerontics
The term Gerontics, or gerontic nursing,
was coined by Gunter and Estes in 1979 to
define the nursing care and the service
provided to older adults. The aim of gerontic
nursing is “to safeguard and increase health to
the extent possible, and to provide comfort
and care to the extent necessary”.

7. Gerontophobia
• The fear of ageing and the refusal to accept
older adults into the mainstream of society is
known as Gerontophobia. Both senior citizens
and younger persons can fall prey to such
irrational fears.
Ageism
• Ageism is the disliking of ageing and older
people based on the belief that ageing makes
people unattractive, unintelligent, and
unproductive. It is an emotional prejudice or
discrimination against people based solely on
age.

8. Theories of ageing
Biological theories
Biological theories attempt to
explain why the physical changes of aging
occur. It is known that all members of a
species suffer a gradual, progressive loss of
function overtime because of their biological
structure.

9. Theories of ageing
• Programmed theory – this theory proposes that
every person has a ‘biological clock’ that starts
ticking at the time of conception. Each individual
has a genetic program specifying an unknown but
predetermined number of cell divisions.
• Run- out -of - program theory – this theory
proposes that every person has a limited amount
of genetic material that will run out over time.

10. • Gene theory – proposes the existence of one
or more harmful genes that activate over
time, resulting in the typical changes seen
with aging and limiting the life span of the
individual.
• Error theory – proposes that errors in
ribonucleic acid protein synthesis cause errors
to occur in cells in the body, resulting in a
progressive decline in biologic function.

11. • Somatic mutation theory – proposes that
aging results from deoxyribonucleic acid(DNA)
damage caused by exposure to chemicals or
radiation and this damage causes
chromosomal abnormalities that lead to
disease or loss of function later in life.

12. • Free radical theory – provides explanation for
cell damage. Free radicals are unstable
molecules produced by the body during the
normal processes of respiration and
metabolism or following exposure to radiation
and pollution. These free radicals are
suspected to cause damage to the cells, DNA,
and immune system.

13. • Cross link or connective tissue theory-
proposes that cell molecules from DNA and
connective tissue interact free radicals to
cause bones that decrease the ability of tissue
to replace itself. This result in the skin changes
typically attributed to again such as dryness,
wrinkles, and loss of elasticity.

14. • Clinker theory – combines somatic mutation,
free radical and crosslink theories to suggest
that chemicals produced by metabolism
accumulate in normal cells and cause damage
to body organs such as the muscles, heart,
nerves, and brain

15. • Wear and tear theory – presumes that the
body is similar to a machine, which loses
function when its part wears out. As people
age, their cells, tissues, and organs are
damaged by internal or external stressors.
When enough damage occurs to the body’s
parts, overall functioning decreases.

16. • Neuro endocrine theory – focuses on the
complicated chemical interactions set off by the
hypothalamus of the brain. With the age, the
hypothalamus appears to be less precise in
regulating endocrine function, leading to age-
related changes such as decreased muscle mass,
increased body fat, and changes in reproductive
function.
• Immunologic theory – proposes that ageing is a
function of changes in the immune system. The
immune system- an important defense
mechanism of the body – weakens over time,
making an ageing person more susceptible to
disease.

17. Psychosocial theories
Psychosocial theories focus on social and
psychological changes that accompany
advancing age, as opposed to the biological
implications of anatomic deterioration.
Several theories have attempted to describe
how attitudes and behavior in the early phases
of life affect people’s reactions during the late
phase. This work is called the process of
“successful aging.”

18. Personality Theory
• Personality theories address aspects of
psychological growth without delineating specific
tasks or expectations of older adults.
• Murray and Zentner (2001) state, “Evidence
supports the general hypothesis that personality
characteristics in old age are highly correlated with
early life characteristics”
• In extreme old age however, people show greater
similarity in certain characteristics, probably
because of similar declines in biological
functioning and societal opportunities

19. • In a classic study by Reichard, Livson, and
Peterson(1962), the personalities of older men
were classified into five major categories
according to their patterns of adjustment to
aging. According to this study:
• 1. Mature men are considered well-balanced
persons who maintain close personal
relationships. They accept both the strengths
and weaknesses of their age, finding little to
regret about retirement and approaching most
problems in a relaxed manner without
continually having to assess blame.

20. 2. Rocking chair” personalities
Are found in passive dependent individuals
who are content to lean on others for support,
to disengage, and to let most of life’s activities
pass them by.
3. Armored men
Have well-integrated defense mechanisms,
which serve as adequate protection. Rigid and
stable, they present a strong silent front and
often rely on activity as an expression of their
continuing independence.

21. 4. Angry men
Are bitter about life, themselves, and other
people. Aggressiveness is common, as is
suspicion of others, especially of minorities or
women.
With little tolerance for frustration, they have
always shown some instability in work and
their personal lives, and now feel extremely
threatened by old age.

22. 5. Self-haters
Are similar to angry men, except that most of
their animosity is turned inward on themselves.
Seeing themselves as dismal failures, being old
only depresses them all the more.
• The investigators identified the mature,
“rocking chair,” or armored categories as
characteristic of healthy, adjusted individuals
and the angry and self hater categories as those
who are less successful in aging.

23. Psychosocial theories
• Disengagement theory – this was developed to
explain why ageing persons separate from the
main stream of society. This theory propose that
older people are systematically separated,
excluded, or disengaged from society because
they are not perceived to be benefit to the
society as a whole.
• Activity theory – proposes that activity is
necessary for successful ageing. Active
participation in physical and mental activities
helps maintain functioning well into old age.

24. • Life- course theories – these theories trace
personality and personal adjustments throughout
a person’s life.
• Erickson’s theory – identifies eight stages of
developmental tasks that an individual must
confront throughout the life span :
1. Trust versus mistrust 2. Autonomy versus
shame 3. Initiative versus guilt 4. Industry versus
inferiority 5. Identity versus identity confusion 6.
Intimacy versus isolation 7. Generativity versus
stagnation 8. Integrity versus despair. The last of
these stages is the domain of late adulthood, but
failure to achieve success in tasks earlier in life
can cause problems later in life.

25. • Havighurst’s theory – details the process of
ageing and defines specific tasks for late life,
including
1. Adjusting to decrease physical strength and
health
2. Adjusting to retirement and decreased
income
3. Adjusting to the loss of a spouse
4. Establishing a relationship with one’s age
group
5. Adapting to social roles in a flexible way
6. Establishing satisfactory living arrangements.

26. • Newman’s theory – identifies the task of
ageing as
1. Coping with the physical changes of ageing
2. Redirecting energy to new activities and
roles, including retirement, grand parenting
and widowhood
3. Accepting one’s own life
4. Developing a point of view about death.

27. • Jung’s theory –
 Proposes that development continues
throughout life by a process of searching,
questioning and setting goals that are
consistent with the individual’s personality.
 Thus, life becomes an ongoing search for
the ‘true self’.

28.  At the stage of mid life, they question
whether the decisions and choices they have
made were the right choices for them.
 This is the so-called ‘midlife crisis’ which
can lead to radical career or lifestyle changes
or to acceptance of the self as is.
 Successful ageing according to Jung,
includes acceptance and valuing of the self
without regard to the view of others.

29. Communicating with older adults-
skills and techniques
• Informing
• Direct questioning
• Open ended techniques
• Confronting

30. Communicating with older adults-
skills and techniques
• Communication with visitors and families
Nurses must be prepared to interact with
their patient’s families, friends and other
visitors. Good communication with these
significant people can do a great deal to
facilitate care. Because they have known the
patient longer and better than the nursing
staff has, they are often able to detect subtle
changes before trained nurses can.

31. Patient teaching
It is important to pick a right place and time for
teaching.
The right place depends on the material the
session will cover.
Information that is viewed as personal or private
is best taught in a quiet place away from others.
More general information like stress reduction,
nutrition teaching, etc may be best taught in a
group, where older adults are free to share their
personal experiences and solutions with one
another.

32. Patient teaching
Barriers to communication
• Hearing impairment
• Aphasia
• Dementia
• Cultural differences

33. PSYCHIATRIC PROBLEMS IN ELDERLY
DEMENTIA
Dementing disorders are the most common
causes of psychopathology in the elderly.
About half of these disorders are of the
Alzheimer’s type, which is characterized by an
insidious onset and a gradually progressive
course of cognitive impairment.
No curative treatment is currently available.

34. Symptomatic treatments, including
pharmacological interventions
 attention to the environment,
 family support, can help to maximize the
client’s level of functioning.

35. DELIRIUM
Delirium is one of the most common and important
forms of psychopathology in later life.
A number of factors have been identified that
predispose elderly people to delirium, including
 structural brain disease
 reduced capacity for homeostatic regulation
 impaired vision and hearing
 a high prevalence of chronic disease
 reduced resistance to acute stress
 age-related changes in the pharmacokinetic and
pharmacodynamics of drugs.

36. Delirium needs to be recognized and the
underlying condition treated as soon as
possible.
A high mortality is associated with this
condition.

37. DEPRESSION
Depressive disorders are the most common
affective illnesses occurring after the middle
years.
The incidence of increased depression among
elderly people is influenced by the variables of
physical illness, functional disability, cognitive
impairment, and loss of a spouse.

38. Hypochondriacal symptoms are common in the
depressed elderly.
Symptomatology often mimics that of dementia,
a condition that is referred to as
pseudodementia.
Suicide is more prevalent in the elderly, with
declining health and decreased economic status
being considered important influencing factors.
Treatment of depression in the elderly individual
is with psychotropicmedications or
electroconvulsive therapy.

39. SCHIZOPHRENIA
Schizophrenia and delusional disorders may
continue into old age or may manifest
themselves for the first time only during
senescence (gradual deterioration of
functional characteristics )
In most instances, individuals who manifest
psychotic disorders early in life show a decline
in psychopathology as they age.

40. Late-onset schizophrenia (after age 60) is not
common, but when it does occur, it often is
characterized by delusions or hallucinations of
a persecutory nature.
The course is chronic, and treatment is with
neuroleptics and supportive psychotherapy

41. ANXIETY DISORDERS
Most anxiety disorders begin in early to
middle adulthood, but some appear for the
first time after age 60.
The fragility of the autonomic nervous system
in older persons may account for the
development of anxiety after a major stressor.

42. Because of concurrent physical disability, older
persons react more severely to posttraumatic
stress disorder than younger persons.
In older adults, symptoms of anxiety and
depression often accompany each other,
making it difficult to determine which disorder
is dominant.

43. PERSONALITY DISORDERS
Personality disorders are uncommon in the
elderly population.
The incidence of personality disorders among
individuals older than age 65 is less than 5
percent.
Most elderly people with personality disorder
have likely manifested the symptomatology
for many years.

44. SLEEP DISORDERS
Sleep disorders are very common in the aging
individual.
Sleep disturbances affect 50 percent of people age 65
and older who live at home and 66 percent of those
who live in long-term care facilities.
Some common causes of sleep disturbances among
elderly people include
 age dependent decreases in the ability to sleep
 increased prevalence of sleep apnea
 depression, dementia, anxiety, pain,impaired
mobility and medications
 psychosocial factors such as loneliness, inactivity,
and boredom.

45. Sedative-hypnotics, along with non-
pharmacological approaches, are often used
as sleep aids with the elderly.
Changes in aging associated with metabolism
and elimination must be considered when
maintenance medications are administered
for chronic insomnia in the aging client.

46. Expected Psycho social changes
Cognition and intelligence
• Fluid intelligence is the ability to perform tasks or
judgments based on unfamiliar stimuli. This is
sometimes referred to as the ‘ability to think on your
feet’.
• Crystallized intelligence (wisdom) is the ability to
perform tasks and make judgments based on the
experience and knowledge acquired throughout a life
time. Because young people have less knowledge and
experience, they must rely more on fluid intelligence.
With advanced age comes an abundance of skills and
knowledge that has been acquired over time, and
crystallized intelligence is more often used.

47. Cognition and language
Language is a product of cognitive
function. In both spoken and written forms,
language allows humans to communicate ideas
and thoughts.
Sensory and cognitive problems can result in
poor language development or loss of language
skills.
Damage to the language centers of the brain can
result in aphasia, a condition which people are
unable to understand or express themselves
through language.

48. Disturbed thought processes
Anything that damages or interferes
with the normal functioning of the cerebral
cortex can result in cognitive (thinking and
judgment) problems.
Cognitive problems can range from mild and
reversible forms of disorientation to severe
and irreversible forms of dementia.
Depression, hypothyroidism, and vitamin
deficiencies are common treatable causes of
pseudodementia

49. Impaired verbal communication
• The most common language problem seen in
older adults is called aphasia (or dysphasia).
Aphasia can be classified in several different
ways.
• Receptive aphasia – here the person has difficulty
in understanding the language
• Expressive aphasia – in which the person is
unable to express himself or herself using
language
• Global aphasia – in which the person loses ability
both to understand and to express himself or
herself using language

50. Depression
Depression is more common in the aging
population. Some changes that warrant
further investigations include
• Stopping normal routines
• Neglected self-care
• Unwillingness to talk
• Agitation and irritability

51. • Suspiciousness or unjustified fears
• Mood swings
• Isolation and withdrawal
• Increased use of alcohol or mood altering
drugs
• Unexplained injuries
• Verbalization of worthlessness
• Verbalization of suicidal thoughts

52. • Substance abuse
Drugs such as anxiolytics, tranquillizers,
analgesics and other mood-altering drugs are
among the most common prescriptions given to
elderly adults. Many times an older person
receives prescriptions from several physicians,
thus increasing the availability and potential for
abuse. Alcohol tolerance changes as a result of
altered physiology. Decreased lean muscle mass,
changes in liver enzyme function and increased
nervous system sensitivity to alcohol decrease
the safe level of intake for the elderly.

53. Suicide and aging
Depressed older adults with a history of
affective disorders are most at risk for
committing suicide. Severe emotional or
physical pain, a recent loss or stressful event
such as diagnosis of a terminal disease are
present in a large percentage of those who
attempt to take their own lives.

54. Sexuality and aging
Physical changes related to aging,
changing health status, and loss of a sex
partner all affect the sexual practices of older
adults. Normal physiologic changes in sexual
function may raise concerns for aging adults.
In general, sexual response time slows down
with aging, but the ability to achieve orgasm
remains throughout the life.

55. Factors that affect sexuality of older adults
• Normal changes in women – dyspareunia,
irritation of external genitals, dryness of
vaginal walls, etc
• Erectile dysfunction in men.
• Illness and decreased sexual function.
• Alcohol and medications
• Loss of a sex partner.

56. SPECIAL CONCERNS OF THE ELDERLY
POPULATION
Retirement
Retirement has both social and economical
implications for elderly individuals. The role is
fraught with a great deal of ambiguity and is
one that requires many adaptations on the
part of those involved.

57. Successful adaptation to retirement
• Remaining actively involved and
having a sense of belonging unrelated
to work
• Re-evaluating life satisfaction related
to family and social relations and
spiritual life rather than to work.
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58. • Re-evaluating the world’s outlook
• Maintaining a sense of health, integrating
mind and body to avoid complaints or illness
when work is no longer the focus.

59. Economical Implications
Because retirement is generally associated
with 20 to 40 percent reduction in personal
income, the standard of living after retirement
may be adversely affected.
Most older adults derive postretirement
income from a combination of Social Security
benefits, public and private pensions, and
income from savings or investments.

60. Long-Term Care
The concept of long-term care covers a broad
spectrum of comprehensive health care and
support services necessary to provide the
physical, psychological, social, spiritual, and
economic needs of people with chronic illness
or disabilities

61. Special Concerns Of The Elderly
Population
Age
Mental health status
Socioeconomic and Demographic
factors
Marital status ,Living Arrangement
and the informal support network

62. Elder Abuse
Elder abuse is a single, or repeated act or lack
of appropriate action, occurring with any
relationship where there is an expectation of
trust, which cause harm or distress to the
older person.

63. Elder Abuse
• Physical Abuse
• Striking, hitting, beating
• Shoving
• Bruising
• Cutting
• Restraining
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64. Elder Abuse
Psychological Abuse
•Yelling
•Insulting, name-calling
•Harsh commands
•Threats
•Ignoring, silence, social isolation
•Withholding of affection
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65. Elder Abuse
Neglect (intentional or unintentional)
•Withholding food and water
•Unclean clothes and bedding
•Lack of needed medication
•Lack of eye glasses, hearing
aids, false teeth

66. Elder Abuse
• Financial Abuse or Exploitation
•Misuse of the elderly person’s
income by the caregiver
•Forcing the elderly person to
sign over financial affairs

67. Elder Abuse
• Sexual Abuse
•Sexual molestation; rape
•Any type of sexual intimacy
against the elderly person’s will
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68. Current standards for the
development of mental health
services for the elderly
• Family and social supports
• A primary health-care team
• A specialist old age psychiatry team
• An inpatient unit
• Rehabilitation
• Day care
• Respite facilities
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69. Current standards for the
development of mental health
services for the elderly
• Range of residential care for people
unable to live in their own homes
• Liaison with general medicine, where
available, geriatric medicine facilities
• Education of health-care providers in
all disciplines, particularly in the
primary health care sector

70. Interventions For Elderly

71. Behavioural Interventions
• attempt to identify and reduce the
antecedents and consequences of problem
behaviors.
• help to reduced some specific problem
behaviors, such as incontinence.

72. Emotion-oriented Interventions
• include reminiscence therapy, validation
therapy, supportive psychotherapy, sensory
integration and simulated presence therapy.
• Supportive psychotherapy has received little
or no formal scientific study, but some
clinicians find it useful in helping mildly
impaired patients adjust to their illness.

73. Reminiscence Therapy (RT)
• has been defined as vocal or silent recall of
events in a person's life, either alone, or with
another person or group of people
• involves the discussion of past experiences
individually or in group, many times with the
aid of photographs, household items, music
and sound recordings, or other familiar items
from the past.

74. Simulated Presence Therapy (SPT)
• is based on attachment theories and is
normally carried out playing a recording with
voices of the closest relatives of the patient.
• which has been reported to reduce levels of
anxiety and challenging behaviour amongst
people with dementia.

75. Sensory Integration Therapy
• Sensory integration is the neurological process of
organizing the information we get from our
bodies and from the world around us for use in
daily life.
• Therapy improve the ability of the brain to
process sensory information so that one will
function better in his daily activities
• In the use of sensory integration in the adult
dementia population significantly improved
cognitive functioning

76. Validation Therapy
• The listener ‘validates’ what is said by listening
to the emotional meaning rather than the
factual content of what is said. This can be
used in group settings or during one-on-one
interaction

77. Cognition-oriented Treatments
• For the Alzheimer's patient, whose thinking
processes are already slowed and impaired, a
treatment approach called reality orientation
was developed
• Reality orientation consists in the presentation
of information about time, place or person in
order to ease the understanding of the person
about its surroundings and his place in them.

78. • Reality orientation is based upon the belief
that continual, repetitive reminders will keep
the patient stimulated and lead to an increase
in orientation.

79. Cognitive retraining
Tries to improve impaired skills by exercitation
of mental abilities
two parts: restoring the actual cognitive skill,
and learning to use strategies to compensate
for the impaired ability.
Cognitive training include considerable amount
of repetitive practice and regular feedback.

80. Stimulation-oriented treatments
• include art, music, pet therapies, exercise and any
other kind of recreational activities for patients.
• Stimulation has modest support for improving
behavior, mood, and to a lesser extent function.
• As important as these effects are, the main
support for the use of stimulation therapies is the
improvement in the patient daily life routine they
suppose.

81. Role of a psychiatric nurse
The nurse manager
• Identify a clear objective
• Identify the right people
• Identify the right approach
• Role model politeness or PTAS (please, thank
you, action, smiles)
• Involve the entire team
• Recognize that little things mean a lot
• Convey compassion and pride in work

82. Role of a psychiatric nurse
• Cheerfulness
• Courtesy
• Cleanliness
• Coaching
• Collaboration
• Communication
• Commitment
• Confidentiality
• Compassion

83. Skills of the nurse managers
• Delegating
• Team building
• Goal setting
• Facilitating change
• Stress management
• Expertise
• Decision making and conflict resolution
• Communication
• Listening
• Inspiring trust

84. The nurse leader
Attributes of nurse leaders
• Personal integrity - holding ethical standards,
trustworthiness, credibility
• Strategic vision/action orientation
• Communication skills
• Management and technical competencies
• People skills – empowering others, collaboration
• Personal attributes – political sensitivity, self –
direction, self-reliance, courage.

85. THANK YOU