PSYCHOSOCIAL ISSUES IN AGING

The physiologic changes of aging can also have major effects on an individual’s psychological and social well-being. Whether life changes are slow or sudden, the result often affects both physical and mental health.

Transitions

People in later life must navigate through many transitions including:

• Retirement
• Changing family structures
• Relocation or downsizing and moving from one’s home
• Losses, grief, and bereavement
• Isolation

These transitions can result in profound changes to routines, roles, and responsibilities, leading to mental health challenges (MHF, 2021).

RETIREMENT

Retirement is often the first major transition for the older adult, and about one third have problems adjusting to different aspects of retirement, including loss of professional identity, altered social roles, and reduced income. Also, some people choose to retire while others may be forced to retire (Kaplan & Berkman, 2019).

CHANGING FAMILY STRUCTURES

Family members have traditionally played a major role in the delay and prevention of institutionalization of chronically ill older adults. About 80% of help in the home (physical, emotional, social, economic) is provided by family caregivers.

However, changing family structures have altered the intergenerational structure of society. Relationships in families have become more fluid and less predictable. Reduced fertility and increased rates of divorce, remarriage, cohabitation, and stepfamily formation have also altered the context in which intergenerational, spousal, and sibling relationships function.

This increasing diversity of family forms raises issues about societal and individual responsibility for the care and well-being of older family members. More and more adults have not had children, which means there are fewer family members to provide company and care as they age (Kaplan & Berkman, 2019).

RELOCATION

Relocation may happen several times during old age, including moving to smaller quarters to reduce burden of upkeep, moving to the homes of adult children, or moving into one of several types of residential facilities, such as senior housing, assisted living, or a nursing care facility. People who adapt poorly to these changes are more likely to live alone, be socially isolated, be poor, and be depressed. Men respond less well than women.

When people perceive a loss of control over a move, the greater their stress around relocation. For the cognitively impaired, a move away from familiar surroundings may exacerbate functional dependence and disruptive behaviors (Kaplan & Berkman, 2019).

LOSSES, GRIEF, AND BEREAVEMENT

Losses, grief, and bereavement bring a decline in social interactions and companionship. The death of a spouse affects men and women differently. In the two years following the death of a wife, the mortality rate for men increases, especially if the wife’s death was unexpected. The same is not true, however, for women.

When people experience many losses, grief can be overwhelming. This cumulative grief is often an under-recognized problem in older adults (Kaplan & Berkman, 2019).

LONELINESS AND ISOLATION

Loneliness and isolation impact physical and mental well-being, bringing more risk for heart disease and stroke as well as Alzheimer’s disease, depression, anxiety, and fearfulness.

While living alone does not necessary result in loneliness in all older adults, it is the biggest single contributing factor. It is typical for older persons to have less contact with others and to become more isolated. While joining groups, volunteering, exercising, and taking lessons or classes are all good ideas for socialization, they are not always possible for the older person. A big roadblock to socialization is a lack of mobility and freedom to move about (Kaplan & Berkman, 2019).

For some, chronic loneliness can become a side effect of a medical or psychological problem, including:

• Substance use
• Depression and bipolar disorder
• Serious illness or disease
• Dementias

Sexual orientation and gender identity issues may also contribute to loneliness or isolation. Research indicates that a large portion of older adults who identify as LGBT (lesbian, gay, bisexual, or transgender) report a high degree of life satisfaction, yet over half report a lack of companionship and feel isolated. More than half are diagnosed with depression, and a third report having suicidal ideation. Over 50% of LGBT adults with HIV live alone. Social isolation arises from the death of partners and disconnection from family. HIV stigma is associated with depression, poorer quality of life, lack of disclosure to others, and loneliness (Emlet & Brennan-Ing, 2020; Kaplan & Berkman, 2019).

Older people in nonheterosexual relationships or who are gender nonconforming face special caregiving challenges. The healthcare system may not be aware of their sexual preference or gender identity and may not recognize their partners as having a role in caregiving decisions or as being part of the patient’s family (Wenker & Liebzeit, 2019).

Depression

Depression is the most common mental health condition in adults ages 65 and older. More than 2 million of the 34 million Americans age 65 and older suffer from some form of depression (MHA, 2021). Negative effects of depression are far-reaching, further complicating existing conditions common among older adults.

Depression in older adults can be difficult to recognize. They may have less obvious symptoms of depression or they may not be willing to talk about their feelings. Often depression in the older adult is confused with the effects of multiple illnesses and the medications used to treat them. Also, due to the belief that the older adult is expected to slow down, family and healthcare practitioners may miss the signs of depression, and effective treatment is often delayed (Wenker & Liebzeit, 2019).

Some of the most common risk factors for depression in this age group include:

• Being female
• Being single, unmarried, divorced, or widowed
• Lack of supportive social network
• Certain medicines or combinations of medicines
• Damage to body image (e.g., amputation, cancer surgery)
• Fear of death
• Social isolation
• Presence of chronic or severe pain
• Recent loss of a loved one
  (Wenker & Liebzeit, 2019; NIA, 2017b)

ASSESSING DEPRESSION

Recognizing the symptoms and screening for depression in older people and referring them for appropriate diagnosis and treatment may greatly improve their quality of life. Symptoms include:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, guilt, worthlessness, or helplessness
• Irritability, restlessness, or having trouble sitting still
• Loss of interest in once pleasurable activities
• Decreased energy or fatigue
• Appetite and/or unintended weight changes
• Sleep disturbance, insomnia, early morning awakening
• Moving or talking more slowly
• Difficulty concentrating, remembering, making decisions
• Thoughts of suicide or suicide attempts
  (NIA, 2017b)

Currently, the Geriatric Depression Scale and Geriatric Depression Scale-15 are the preferred instruments to use when screening for depression in the older adult (Galsamo et al., 2018).

MANAGEMENT OF DEPRESSION

Treatment for depression may include the following:

• Antidepressants
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Psychotherapy
  • Cognitive Behavioral Therapy (CBT), including a version called problem-solving therapy that may be especially useful for treating older adults and improving quality of life
  • Interpersonal psychotherapy
  • Self-management or self-control therapy
• Complementary therapies
  • Yoga
  • Exercise
  • Omega 3 fatty acids
  • St. John’s wort in mild to moderate, but not severe, depression
• Electroconvulsive therapy (ECT) for severe depression that is very difficult to treat and does not respond to medication or psychotherapy
• Stimulation techniques, including transcranial magnetic stimulation (TMS), which is approved by the FDA for use in adult patients who have failed to respond to medications and/or ECT treatment
  (NIMH, 2020)

Depressed patients may require assistance with self-care and personal hygiene. Medication compliance is stressed, and close monitoring for warning signs of suicide is important during treatment, as risk of suicide increases with lifting of depressed mood. Patients are also advised to work with their providers when discontinuing medications to avoid antidepressant withdrawal, sometimes called antidepressant discontinuation syndrome (Hall-Flavin, 2019).

Suicide

Suicide is the 17th leading cause of death among people ages 65 and older. Rates tend to increase over time, and risk of suicide tends to follow birth cohorts. Baby boomers have had the highest rate. White older males have a higher suicide rate than females, and white males aged 85 and older have a four times higher rate than the nation’s overall rate. Suicidal ideation is more commonly openly endorsed by persons in the oldest-old age group (Wenker & Liebzeit, 2019).

Compared to younger people, older adults tend to be more deliberate in their planning of suicide, with the top three means of dying by suicide being firearms, suffocation, and poisoning. Although older adults attempt suicide less often, they are more successful.

It is important to recognize that older adults also may use less aggressive and less visible methods referred to as passive suicide. These may include:

• Refusal to eat, leading to malnutrition
• Refusal of fluids, leading to dehydration
• Refusal to take maintenance medications
• Refusal to accept care in emergent situations

Risk factors for suicide among older persons often differ from those among the young. In addition to a higher prevalence of depression, suicidal risk factors and warning signs in older persons include:

• Depression
• Prior suicide attempts
• Marked feelings of hopelessness, lack of interest in future plans
• Feelings of loss of independence or sense of purpose
• History of military service
• Medical conditions that significantly limit functioning or life expectancy
• Chronic pain
• Impulsivity due to cognitive impairment
• Social isolation
• Family discord or losses
• Inflexible personality or marked difficulty in adapting to change
• Access to lethal means
• Sudden personality changes
• Alcohol or medication misuse or abuse
• Verbal suicide threats (e.g., “You’ll be better off without me.”)
  (Wenker & Liebzeit, 2019; MHA, 2020)

Suicide protective factors include:

• Family and community support
• Support from ongoing medical and mental healthcare relationships
• Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes and coping with stress
• Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
  (CDC, 2019a)

ASSESSMENT OF SUICIDE RISK

The goal of suicide risk assessment is not to predict whether or not an older person will die by suicide but to determine the most appropriate actions to take to keep the person safe. It is also important to remember that older adults are less likely to spontaneously report suicide ideation, and it is up to clinicians to ask. Healthcare providers have a great number of opportunities to identify and intervene with suicidal patients; it is helpful to remember that a majority of people who die by suicide had visited a healthcare provider in the month prior to their suicide (Van Orden, 2020).

The Columbia Suicide Severity Rating Scale (C-SSRS) is becoming the gold standard for suicide risk assessment. This tool asks the following six questions:

• Have you wished you were dead or wished you could go to sleep and not wake up?
• Have you had any actual thoughts of killing yourself?
• Have you been thinking about how you might do this?
• Have you had these thoughts and had some intention of acting on them?
• Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
• Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Positive responses to all 6 questions indicate the need for behavioral health referral, and positive responses to question 3, 4, 5, and 6 indicate the need for taking patient safety precautions.

Tools for assessing both passive and active ideation also include the Patient Health Questionaire-9 (PHQ-9) depression screening tool, which assesses nine symptoms of depression and how often persons have had thoughts that they would be better off dead or wish to hurt themselves in some way. The Geriatric Suicide Ideation Scale (GSIS) can be used to monitor changes in suicide risk across the course of treatment (Van Orden, 2020; Columbia Lighthouse Project, 2016).

DETERMINING LEVEL OF SUICIDE RISK

Risk Level	Risk and Protective Factors	Suicide Screening Results
(MNDH, 2019)
Low	Few and/or modifiable risk factors Strong protective factors	Thoughts of death with no plan, intent, or behavior
Moderate	Multiple risk factors Few protective factors	Suicidal ideation with a plan, but no intent or behavior
High	Multiple risk factors Lacks protective factors	Has made a potentially lethal suicide attempt, or Has persistent ideation with strong intent or suicide rehearsal

MANAGEMENT OF SUICIDE RISK

If an individual reports having passive or active suicide ideation, it is important to follow up to determine whether the individual has current intent to act on their thoughts. Passive suicidal thoughts include thinking that one would be “better off dead.” These thoughts are not necessarily associated with increased risk for suicide but are a sign of significant distress and should be addressed immediately.

In contrast, active suicidal thoughts include thinking of taking actions toward hurting or killing oneself. These thoughts require immediate clinical assessment and intervention by a mental health professional.

For those categorized as low risk, intervention should include:

• Outpatient referral
• Creating a safety plan
• Urging removal of means for suicide from the home
• Providing emergency/crisis numbers (e.g., 800-273-TALK)

For those with moderate risk:

• Possible hospitalization
• Developing a crisis plan
• Taking suicide precautions
• Providing emergency/crisis numbers

For those at high risk, the appropriate intervention is hospitalization. It is necessary to remain with the patient until appropriate actions have been taken and emergency services are in place. These actions may include calling 911 to obtain emergency department care or contacting a mobile crisis team (Van Orden, 2020).

Sexuality

Aging introduces issues that affect sexual activity. (See also “Endocrine Changes” earlier in this course.) Providers must also recognize that changes affecting the sexual health of one member of a couple also affect the other partner. Taking a couple-oriented approach to management can be helpful in improving sexual satisfaction and intimacy.

Sexuality remains an important part of life into older age, but older people are often challenged by ageist attitudes and perceptions that interfere with sexual expression. Older adults are stereotyped as nonsexual beings who should not, cannot, and do not want to have sexual relationships. These myths of ageism include:

• Older adults lack sexual desire
• Older people, particularly women, are physically unattractive and undesirable
• Engaging in sexual activity is shameful and perverted
• There are no older lesbian, gay, bisexual, transgender, queer (LGBTQ) people

Ageist attitudes are not uncommon among healthcare providers, and they have a large impact on the legitimacy of expressing sexuality later in life. A particularly significant indication of internalizing ageism is the reluctance of older people to discuss sexual issues with their primary care physicians due to fear that sex in later life does not meet with societal expectations and will, therefore, be disapproved of by healthcare providers. It has also been found that sexual issues are not raised by healthcare providers during routine healthcare visits or other interactions with older people. A survey of providers found that only 40% of providers routinely ask questions of all patients to assess for sexual problems or dysfunction and fewer than a third (28%) routinely confirm a patient’s sexual orientation (ASHS, 2020).

Attitudes toward sexuality in later life among staff in long-term care facilities defines the institutional stance on this issue, which can range from restricting sexual expression to being responsive to or even promoting residents’ sexual needs.

Prior to entering care facilities, prospective residents are not provided with information about how their sexual and intimacy needs will be respected, nor do nurses routinely inquire about sexual practices or conduct sexual health assessments among older residents.

In general, staff knowledge regarding later-life sexuality is limited. Simple circumstances required for sexual expression, such as privacy, are not facilitated. Sexual expression among LGBTQ individuals can be even more difficult in long-term care facilities, where any kind of sexual expression is censored or where judgments are made about those who are not in long-term relationships or have multiple sexual partners. When a person also has dementia, sexual disinhibition might be quickly labeled as deviant (Gewirtz-Meydan et al., 2018).

Substance Use in Older Adults

While illicit drug use typically is much lower in older adults than younger adults, it is currently increasing. Nearly 1 million older adults are living with a substance use disorder. Aging can lead to social and physical changes that may increase vulnerability to substance misuse.

Many older adults may use alcohol simply because it is a long-term habit that is part of their lifestyle. Some may take substances to cope with big life changes such as retirement, grief and loss, declining health, or a change in living situation. Others may take them to relieve chronic pain. Some people may unintentionally misuse prescription or OTC medications by forgetting to take them, taking them too often, or taking the wrong amount.

Older adults may be more likely to experience mood disorders, lung and heart problems, or memory issues, and drug and alcohol use can worsen these conditions. Additionally, some drugs can impair judgment, coordination, or reaction, which can result in accidents, including falls and auto crashes. Little is known, however, about the effects of drugs and alcohol on the older brain. Older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs.

Regular marijuana use for medical or recreational reasons at any age is associated with chronic respiratory conditions, depression, impaired memory, adverse cardiovascular function, and altered judgment and motor skills. Marijuana can interact with a number of prescription drugs and complicate existing health issues.

Regular nicotine use via smoking increases the risk for heart disease and cancer. About 8 in 100 adults ages 65 and older smoke cigarettes. Older people who smoke have an increased risk of becoming frail, though smokers who have quit do not appear to be at higher risk (NIDA, 2020).

Alcohol is the most frequently used substance among older adults, with approximately 65% reporting high-risk drinking, defined as exceeding daily guidelines at least weekly in the past year (NIDA, 2020). The National Institute on Alcohol Abuse and Alcoholism guidelines recommend adults over the age of 65 who do not take medications to limit their alcohol consumption to seven drinks a week, while not drinking more than three drinks on a given day (AAC, 2020).

More than one tenth of older adults currently binge drink, defined as five or more drinks on the same occasion for men and four or more for women. Alcohol use disorder increases the risk for a range of health problems, including diabetes, hypertension, congestive heart failure, liver and bone problems, memory issues, and mood disorders.

Between 4% and 9% of adults ages 65 and older use prescription opioid pain medications for pain relief. The proportion of older adults using heroin (an illicit opioid) has more than doubled since 2013 in part due to the fact that some people who misuse prescription opioids switch to this less costly drug (NIDA, 2020).

Physical risk factors for substance use disorders can include:

• Chronic pain
• Physical disability or reduced mobility
• Transitions in living or care situations
• Change in income
• Chronic illness

Psychiatric risk factors include:

• Avoidance coping style
• Bereavement
• History of substance use disorders
• Previous or current mental illness
• Feeling socially isolated
  (NIDA, 2020)

ASSESSMENT FOR SUBSTANCE USE

Despite the increasing prevalence of substance use among older adults, they are less likely to be screened compared to younger adults. Screening for substance use faces many barriers including challenges of integrating screening in primary care and inpatient settings, as well as the lack of assessment guidelines for older adults who may be using. Another barrier is the discomfort experienced by both patients and providers discussing and reporting this stigmatized behavior. Also, the signs and symptoms of substance use may be mistaken for manifestations of chronic disease (Han & Moore, 2018).

Signs of drug abuse in the older adult may include:

• Memory problems
• Changes in sleep habits
• Unexplained bruises
• Irritability, sadness, depression
• Unexplained chronic pain
• Changes in eating habits
• Wanting to be left alone
• Self-neglect
• Losing touch with loved ones
• Lack of interest in usual activities
  (Juergens, 2020)

When assessing individuals about substance use, it is important to use language that does not further stigmatize. It is recommended to use wording such as substance use disorder, unhealthy use, and harmful use.

Several screening instruments for substance use are available for a range of substances (alcohol, tobacco, illicit drugs, and prescription drugs), but only a few are designed specifically for and validated in older adults.

One example of a validated screening tool that is commonly used with older adults in the primary care setting is the Substance Use Brief Screen (SUBS), a self-administered brief screen for tobacco, alcohol, and drug use (illegal and prescription). Screening positive with this tool would lead to further screening with longer, more reliable tools (Han & Moore, 2018).

Another screening tool validated for the older adult is the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G), which asks the following 10 questions:

1. When talking with others, do you ever underestimate how much you drink? (yes/no)
2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you did not feel hungry? (yes/no)
3. Does having a few drinks help decrease your shakiness or tremors? (yes/no)
4. Does alcohol sometimes make it hard for you to remember parts of the day or night? (yes/no)
5. Do you usually drink to relax or calm your nerves? (yes/no)
6. Do you usually take a drink to take your mind off your problems? (yes/no)
7. Have you ever increased your drinking after experiencing a loss in your life? (yes/no)
8. Has your doctor or nurse ever said they were worried or concerned about your drinking? (yes/no)
9. Have you ever made rules to manage your drinking? (yes/no)
10. When you feel lonely, does having a drink help? (yes/no)

A score of 2 or more yes responses to this screening is an indication of a problem with alcohol (Medscape, 2020).

More comprehensive and reliable assessment tools may include:

• Quantity-Frequency Index asks about the quantity and frequency of use and the social and health consequences of drug use, including nicotine, prescription, over-the-counter, herbal and food supplements, recreational drugs, and alcohol.
• Alcohol, Smoking, and Substance Involvement Screening Tests (ASSIST) screens across all substances, including tobacco, alcohol, and illegal drug use. The ASSIST is widely used in clinical practice after a screening has been done and found positive.
• The longer Michigan Alcohol Screening Test-Geriatric Version (MAST-G) is the first instrument specifically designed to identify alcohol use problems in older adults. The MAST-G has 24 yes/no questions, with five or more positive responses indicating problematic alcohol use. The questions focus more on potential stressor and behaviors that are common among older adults. The MAST-G has a high sensitivity and specificity and generally has strong psychometric properties.
  (Han & Moore, 2018; NIDA, 2020; Naegle, 2020)

MANAGEMENT AND PREVENTION OF SUBSTANCE USE

The misuse and abuse of substances by the older adult presents unique challenges for recognizing the problem and determining the most appropriate treatment interventions. Misuse is the intentional use, for therapeutic purposes, of a drug by an individual in a way other than prescribed by the healthcare provider or for whom it was not prescribed. Abuse is the intentional nontherapeutic use of a drug, even once, for its desirable psychological or physiologic effects (U.S. FDA, 2019).

The majority of older adults at risk for problem substance use do not need formal, specialized substance abuse treatment. However, many can benefit from prevention messages, screening, and brief interventions.

A brief intervention involves talking with the person about the results of screening and risks associated with substance use and providing educational materials. During this intervention, the clinician can advise the patient to make a behavior change. Advising includes listening to the patient’s concerns about change and attempting to understand alcohol and drug use from the patient’s perspective. Readiness for change can be assessed using the Readiness Ruler rating scale to determine how the patient rates their readiness to change on a scale from 1 to 10 (see “Resources” at the end of this course).

In some instances, a clinician may refer a patient for specialty substance abuse assessment and care. However, treatment options specifically tailored for older adults are limited. Unfortunately, too few older adults who need treatment obtain it, as there are too few addiction providers effectively trained to work with older adults and not enough geriatric specialists with training in addressing substance abuse among this population (Fulmer & Chernof, 2019).