The medical model in psychiatry assumes medical intervention is the treatment of choice for the constellations of diagnosed symptoms that comprise various mental disorders. These treatments may include pharmacotherapy, electroconvulsive treatment, brain stimulation, and psychosurgery. Therefore, psychopharmacology for older adults can be considered palliative rather than a cure for a brain disease causing psychopathology. Older adults experience many psychopathological problems, including anorexia tardive, anxiety disorders, delusional disorders, mood disorders, personality disorders, schizophrenia, and co-occurring disorders with substance abuse/dependence disorders. Therefore, it is critical for the social worker to understand the various manifestations of psychological problems in older adults from the perspective of an older adult, rather than extrapolating information commonly taught in social work programs that neglect to focus on older adults and restrict teaching to psycho-pathological problems in younger and middle-aged adults.
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The baby boom cohort brings with it multiple types of substance abuse. Bisexual older adults have more co-occurring psychological problems than heterosexual older adults, older gay males, and older lesbians. An interesting finding is that immigration is contributory to older adult substance abuse. Older adults with alcohol-abuse problems do not seek help for their problems. Rather, they are often identified as having an alcohol-use problem when seeking care for other medical or psychological problems. Social workers assessing an older adult for alcohol abuse often confuse symptoms of possible alcohol abuse with dementia. Prescribing opioids and synthetic opioids to an older adult is complicated. An older adult can suffer from many forms of inner tension. Combining motivational interviewing with cognitive behavioral therapy is shown to be more effective for treating substance abuse that either therapeutic modality alone.
For older adults, the phenomenon of death is accepted and does not induce the fear experienced by younger adults. Older adults who do not engage in end-of-life planning may receive unwanted, unnecessary, costly, and painful medical interventions or withdrawal of desired treatment. Many older people feel that the goal of palliative care is to make the best possible dying experience for the older adult and his/her family. In addition to palliative care, an older adult will most likely find himself or herself in an intensive care unit as part of his or her terminal care. Euthanasia, or hastened death, is seen by some as an alternative to palliative care. A psychological aspect of death that an older adult is concerned with, in addition to place of death, is whether he or she will die in his or her sleep or die suddenly, making the death experience an individual phenomenon.
Housing communities for older adults are not a contemporary concept. The guiding concept of creating older communities is the desire to give older adults an alternative concept of housing that will allow them to sustain themselves economically, while giving choice and an element of control over their health care, social networks, and physical environment. Many older adults choose retirement communities for an added sense of personal security and continued independent living as a beginning preparation for their ultimate mortality. Aging in place encompasses an older adult staying in his or her home throughout the aging cycle or moving to housing that provides limited services such as an option for communal dining, cleaning services, and transportation. Like aging-in-place strategies, continuing care and assisted living facilities provide medical and nonmedical living services to older adults who are unable to live independently because of medical illness, cognitive decline, or disability.
The therapeutic alliance works based on the idea that the social worker is a willing participant whose primary concern is to support an older client’s effort for desired change. When considering theoretical orientations to treating an older adult that are consistent with the short-term constraints found in most mental health agencies, one is faced with a multitude of theories, some extended for older adults, most created for younger adults. Cognitive behavioral therapy (CBT) and various interpersonal psychotherapies are effective for older adults, though an older adult’s response to these therapies may have a different temporal course and require modifications in technique. Constructivist theory is a conceptual framework that is foundational to existential therapy, CBT, and narrative therapy. However, for older adults, reminiscence is a strength-based strategy employed to validate a sense of intimacy with the past, to integrate the many transitions of life, and as a preparatory method for death.
The process of assessing an older adult occurs on two levels. The first level takes place when an older client presents for assessment. The second level of the assessment process is used for gathering facts that are analyzed for diagnosis, treatment planning, and disposition. Most social workers treating older adults will be younger than their clients. Therefore, clinical authority and respect may become an issue. It is common to treat older adults experiencing hearing deficits who have trouble perceiving high frequencies. The social worker must evaluate the status of the client’s housing, transportation, food, clothing, recreation opportunities, social supports, access to medical care, kinship, contact with neighbors, and other environmental resources that the client or social worker considers important. During the collection of this data, the opportunity will arise while discussing social relationships to collect historical information on the client’s psychosocial development.
Medical problems challenge older adults’ abilities to cope with illness, and at times they experience co-occurring psychological disorders. Therefore, social workers must provide services to assist older adults who are experiencing acute or chronic medical conditions. Older adults experiencing arthritic pain often experience a co-occurring depression. The major cancers experienced by older adults are breast cancer; chronic lymphocytic leukemia; lymphocytic lymphoma; colorectal cancer; lung cancer; mouth, head, and neck cancers; multiple myeloma; prostate cancer; skin cancers; and vulvae cancer. Those older adults suffering from diabetes have a greater chance of co-occurring vascular and cardiovascular conditions and a greater rate of institutionalization and subsequent mortality. Coordination with family members and caregivers about self-care issues, medicine compliance, safety issues, health socialization, and exercise is important because social workers often overlook psychoeducation with medically ill clients.
Stigma is the foundation that distorts the many social constructs affecting how social workers view older adults. Many socially constructed optics produced by stigma can bias social workers’ views of older people. It is important for a social worker to understand that race, ethnicity, and sexual orientation are social constructs that bias clinical care. Additionally, stigma associated with race, ethnicity, and sexual orientation produce psychosocial stressors that converge on older clients, which exacerbate their physical and psychological health statuses. The stigma of mental illness serves to increase the suffering of older people struggling with psychological problems while increasing the suffering of family members, loved ones, and caregivers who experience courtesy stigma. The stigma of suffering from mental illness may also prevent an older person from seeking treatment for his or her psychological problems. Older adults suffering from dementia also suffer from the negative reactions to them because of their diagnosis.
The concept of being an old gay male adult, old lesbian adult, old bisexual adult, or old transgender adult is remote and insignificant to most people. There is an abundance of literature about the younger lesbian, gay, bisexual, and transgender (LGBT) community and a dearth of literature about the older LGBT community. Coming out is a difficult process for anyone, at any developmental stage. It is most difficult when old gay men or old lesbians do not initiate a decision to disclose their sexual identity until late life. Older adults with HIV disease are a significant subpopulation of the current older adult cohort. Transgender older adults are more likely to have a history, as compared with nontransgender people, of sex work, substance and alcohol abuse, and depression. Advocacy model can be adapted to meet the social and clinical needs of the LGBT community.
In older adults, sexual activity declines as a result of multiple causes like medical illness, disability, psychological problems, and social constructs that exist in institutional settings. Another phenomenon of older adult sexuality is that many older adults are aging without major health problems that would limit their sexual functioning. Older men often reveal their problem with erectile dysfunction to a health care provider or social worker. There are multiple approaches to treating erectile dysfunction in older men. The first and primary intervention is referral to an urologist. Functional problems contributing to the decline in sexual activity of older women include co-occurring anxiety or depression, urinary incontinence, thyroid conditions. Many older adults suffering from various forms of dementia become sexually disinhibited and show increasing hypersexuality as their cognitive deficits increase. Social workers have an opportunity to provide psychoeducation to families and caregivers in managing hypersexuality exhibited by patients suffering from dementia.