1 . What percentage of the U.S. population is currently made up of older adults (65 years and older)?
The oldest person in the United States is 115 years old, and
in the 2010 Census, there were 53,364 centenarians (individuals 100 years of age or older)
[1]. Older adults, considered to be
individuals 65 years of age and older, make up 16% of the U.S. population. Moreover, the
number of individuals 85 years of age and older is projected to double by the year 2040, and
by 2050, it is projected that one in five people in the United States will be older than 65
years of age [2,3]. By the year 2060, it is projected that
589,000 people will be 100 years of age or older [4]. These figures alone demonstrate the need for increased familiarity and
comfort with the mental health care of the older adult. Aside from age, the older adult
presents with other potential complications, such as living in extended care
facilities.
2 . By the year 2060, how many people are projected to be 100 years of age or older in the United States?
| A) | | 53,364 |
| B) | | 289,000 |
| C) | | 489,000 |
| D) | | 589,000 |
The oldest person in the United States is 115 years old, and
in the 2010 Census, there were 53,364 centenarians (individuals 100 years of age or older)
[1]. Older adults, considered to be
individuals 65 years of age and older, make up 16% of the U.S. population. Moreover, the
number of individuals 85 years of age and older is projected to double by the year 2040, and
by 2050, it is projected that one in five people in the United States will be older than 65
years of age [2,3]. By the year 2060, it is projected that
589,000 people will be 100 years of age or older [4]. These figures alone demonstrate the need for increased familiarity and
comfort with the mental health care of the older adult. Aside from age, the older adult
presents with other potential complications, such as living in extended care
facilities.
3 . What percentage of individuals aged 85 years and older live in extended-care facilities?
The probability of an older adult living in an extended-care
facility increases with age, with 1% of individuals 65 to 74 years of age, 2% of those 75 to
84 years of age, and 8% of those 85 years of age and older living in an extended-care facility
[2]. As the general population grows older,
it is expected that the number of those in extended-care facilities will increase as
well.
4 . What is the most common form of dementia in older adults?
| A) | | Alzheimer disease |
| B) | | Vascular dementia |
| C) | | Lewy body dementia |
| D) | | Frontotemporal dementia |
MENTAL HEALTH CONCERNS IN THE ELDERLY
Dementia is a general term for difficulties with cognitive
functioning, including impairment in executive functioning (e.g., balancing a checkbook),
memory loss, poor judgment, impulsivity, getting lost in familiar places, and taking longer
than usual to complete daily tasks. Although the likelihood of developing dementia increases
as one ages, it is not considered a normal part of aging. Dementia is further categorized by
type and severity. Alzheimer disease is one of the most common forms of dementia, with an
estimated 6.5 million individuals 65 years of age and older in the United States affected
[6]. Other types of dementia include
frontotemporal dementia, vascular dementia, and dementia with Lewy bodies. It has been
suggested that the total number of Americans with some form of dementia could rise to 14
million by 2040 [7].
5 . All of the following are common characteristics of the oldest individuals who complete suicide, EXCEPT:
| A) | | Dementia |
| B) | | Depression |
| C) | | Loneliness |
| D) | | Facility residence |
MENTAL HEALTH CONCERNS IN THE ELDERLY
Suicide is a public health concern in the United States and
worldwide; in 2020, older adults experienced a suicide mortality rate of 16.86 deaths per
100,000 population [13]. Loneliness,
dementia, and depression are commonly seen characteristics of the oldest individuals who
complete suicide; also, older men had the highest rates of death by suicide in nearly all
countries [14]. The older adult is more
likely to choose a more violent means of attempting suicide and are more likely to die
following an attempt than younger patients [5]. Working with older adults through complex grief, finding meaning in
life, relieving psychiatric symptoms, and, above all, establishing a strong therapeutic
alliance are crucial to improving quality of life and decreasing suicide risk [12]. Problem solving and problem adaptation
therapy are two psychotherapeutic modalities that have shown some promise in decreasing
suicide risk in the older adult [12].
Contributing factors should be continually assessed by the nurse caring for the older
adult.
6 . What is the prevalence rate of anxiety disorders in older adults?
| A) | | 2% to 5% |
| B) | | 7% to 14.2% |
| C) | | 15% to 20% |
| D) | | 25% to 30% |
MENTAL HEALTH CONCERNS IN THE ELDERLY
Anxiety disorders are thought to be more common in older
adults than depression, with a prevalence rate of 7% to 14.2% for this population [12]. Anxiety can manifest differently in older
individuals compared to younger populations due to various factors, including age-related
changes, comorbidities, and life circumstances. Furthermore, the older patient may also
experience lower self-confidence, reduced activity and movement, loss of friends/social
supports, reduced financial and physical independence, and medical comorbidities, all of
which can further fuel anxiety symptoms [16]. These factors culminate to the development of anxiety surrounding death among older
adults; additionally, generalized anxiety disorder, anxiety related to a general medical
condition, and agoraphobia are more likely to occur in late adulthood [12,17]. As individuals get older, they may experience death anxiety, or a
heightened awareness and fear of death, whether conscious or unconscious. The mental health
and quality of life of the older adult improves if death anxiety is addressed
psychotherapeutically. Lower death anxiety is associated with higher levels of meaning in
life [18]. Nurse psychotherapists can be
very important in helping the older adult patient find meaning in life to mitigate the risk
of depression and anxiety in late life [12].
7 . Which of the following is a characteristic of late-onset schizophrenia compared to early-onset?
| A) | | More severe symptoms |
| B) | | More negative symptoms |
| C) | | Worse cognitive impairment |
| D) | | Better premorbid functioning |
MENTAL HEALTH CONCERNS IN THE ELDERLY
Characteristics of schizophrenia in older adults can vary
widely from younger individuals diagnosed with the disorder [24]. This may be due to a combination of a
different symptom profile among those with late-onset schizophrenia and significant symptom
reduction among those with early-onset disease who have reached older adulthood. Older
adults with schizophrenia are also more likely to have acquired medical comorbidities that
complicate the clinical picture. It has been noted that individuals with late-onset
schizophrenia have better premorbid functioning than those who develop the disorder earlier
in life [23]. Those who develop
schizophrenia later in life tend to have fewer negative symptoms and less severe
neurocognitive impairments [23].
8 . Which of the following best describes the principle for medication management in older adults?
| A) | | "Start low, go fast" |
| B) | | "Start high, go slow" |
| C) | | "Start high, go fast, stop if needed" |
| D) | | "Start low, go slow, don't stop, be patient" |
PSYCHOPHARMACOTHERAPY IN OLDER ADULTS
When formulating a treatment plan for older adults,
nonpharmacologic options should be considered first as a safer alternative. If medication is
necessary, adhering to the principle of "start low, go slow, don't stop, be patient" is
crucial [30]. "Start low" acknowledges that
older adults often require lower initial doses compared to younger patients. In some cases, as
little as half or even one-quarter of the recommended starting dose may be appropriate for
older adults [21,30]. "Go slow" advises avoidance of aggressive
dose titration commonly used with younger patients. "Don't stop" emphasizes the need to avoid
abrupt discontinuation of antipsychotics or any medications in the elderly. "Be patient"
suggests allowing older patients sufficient time to adjust to new medications. Demonstrating
patience is important when evaluating the effectiveness of psychiatric medication in older
adults. Even with a low dose, they may still be sensitive to side effects, so close monitoring
is essential to prioritize the safety of the older adult.
9 . Which physiological change occurs in older adults that affects drug metabolism?
| A) | | Decreased body fat |
| B) | | Increased muscle mass |
| C) | | Increased total body water |
| D) | | Decreased total body water |
PHARMACOKINETICS IN OLDER ADULTS
It is common knowledge that as individuals age, total body
water content decreases, muscle mass decreases, body fat increases, and function of several
organ systems (e.g., hepatic, renal) decrease. These age-related changes can contribute to
differences in drug absorption, distribution, metabolism, and excretion. However, nurses
should consider (on an individual basis as much as possible) to what extent these body
systems have and will change. For example, glomerular filtration rate (GFR) can decrease
with age, and this is considered a normal part of aging [87]. Further, some degree of decreased liver function is expected as hepatic
size and blood flow decrease with age. Despite some degree of decreased function, enzyme
induction of the CYP450 system can remain relatively unchanged in the older adult; others
may experience a decrease of up to 30% of enzyme action [88]. Genetics may play a greater role in aging and in pharmacokinetics and
drug metabolism in older adults than is generally appreciated [89]. Although decreases in hepatic and renal
function are highly variable from patient to patient, an overall decrease in both hepatic
and renal function is expected and should be part of prescribing decisions and drug
monitoring in this group.
10 . What percentage of adults 65 years of age and older have at least one chronic condition?
PHARMACOKINETICS IN OLDER ADULTS
As a patient ages, they are increasingly likely to accrue
medical comorbidities. The NCOA has reported that 80% of adults 65 years of age and older
have at least one chronic condition, while 68% have two or more [5]. Medical concerns to be particularly
watchful of in older adults include dehydration, hyponatremia, and impaired renal function.
Some of the most common medical comorbidities in older patients include hypertension, type 2
diabetes, osteoarthritis, coronary artery disease, and hyperlipidemia—all of which often
require at least one medication for control [5].
11 . What is a key consideration when prescribing antipsychotics to older adults with dementia?
| A) | | They should be used as first-line treatment. |
| B) | | They can be prescribed without monitoring. |
| C) | | They have minimal side effects in older adults. |
| D) | | They should be limited to severe or dangerous symptoms. |
Despite this extensive side effect profile, first- and
second-generation antipsychotics still cautiously have a place in a treatment regimen for
older adult patients. A commentary on the Expert Consensus
Guidelines for Using Antipsychotic Agents in Older Patients suggests that it
is inappropriate to use antipsychotic medications in the older adults with generalized
anxiety disorder, panic disorder, insomnia, nonpsychotic major depressive disorder, and
severe nausea and vomiting [44]. The 2016
APA guidelines recommend that use of non-emergency antipsychotic agents for treatment of
dementia-related psychosis should be limited to those patients with severe or dangerous
symptoms or symptoms that cause significant distress to the patient (or care partner)
after objective discussions about the risks and benefits. Second-generation antipsychotics
(e.g., brexpiprazole, pimavanserin) are often considered for short-duration off-label use
under close monitoring when absolutely necessary [45]. Antipsychotic medications can be used with caution in the older adult
with schizophrenia and bipolar disorder.
12 . According to the Beers criteria, which antidepressant should be avoided in older adults due to strong anticholinergic effects?
| A) | | Sertraline |
| B) | | Fluoxetine |
| C) | | Paroxetine |
| D) | | Citalopram |
The Beers criteria identify antidepressants with strong
anticholinergic activity, alone or in combination, as drugs to avoid in older adults, as
these medications are sedating and may cause orthostatic hypotension. Specifically,
antidepressants to avoid include amitriptyline, amoxapine, clomipramine, desipramine,
doxepin (>6 mg/day), imipramine, nortriptyline, and paroxetine. The effects of these
agents predispose older adults to falls and related injury [31]. Paroxetine affects both anticholinergic
and antihistamine receptors, leading to more sedation compared to other SSRIs [47]. It is worth noting that doxepin in doses
of 6 mg or less has a safety profile similar to placebo.
13 . What is the recommended maximum dose of risperidone for older adults with dementia according to APA guidelines?
| A) | | 0.5 mg |
| B) | | 1.0 mg |
| C) | | 1.5 mg |
| D) | | 2.0 mg |
Patients with behavioral and psychological symptoms of
dementia are at heightened risk for psychiatric medication-related risks and side effects
associated with the antipsychotic medications. The American Psychiatric Association (APA)
guidelines suggest deprescribing antipsychotic medications to older patients with dementia
after three months [50]. There is a lack of
consensus of the dosing recommendations for older adults with dementia, and higher
antipsychotic dosages have been associated with worse discontinuation syndromes among these
patients [51]. The APA recommend limiting
doses to maximums of 50 mg of quetiapine, 1.75 mg of olanzapine, and 0.5 mg of risperidone
in those with dementia [51].
14 . Which type of therapy focuses on reflections of life and the aging process using remote memory?
| A) | | Phototherapy |
| B) | | Group therapy |
| C) | | Reminiscence therapy |
| D) | | Cognitive-behavioral therapy |
NONPHARMACOLOGIC TREATMENT OPTIONS
Reminiscence therapy is a treatment that places focus on
reflections on life and the aging process and makes use of the patient's remote memory
[12,64]. Simple, or unstructured, reminiscence therapy focuses on the telling
of life events with focus on the positive to enhance well-being. Unstructured reminiscence
therapy can be done in a group format and does not have to be provided by a
psychotherapist. Conversely, structured reminiscence therapy involves moving through the
life events in an organized way and reframing thoughts about the events in a positive
light [12].
15 . What is the recommended light intensity for phototherapy treatment?
| A) | | 500–1,000 lux |
| B) | | 1,500–10,000 lux |
| C) | | 11,000–15,000 lux |
| D) | | 15,000–20,000 lux |
NONPHARMACOLOGIC TREATMENT OPTIONS
Phototherapy, also known as bright-light therapy, is a
nonpharmacologic intervention most notably used in the treatment of seasonal affective
disorder. With this approach, the patient follows the daily habit of sitting in front of a
1,500–10,000 lux lightbox each morning before sunrise [21]. One study explored the use of phototherapy in the treatment of
mild-to-severe dementia. The researchers found that the phototherapy was more effective in
managing the behaviors associated with severe dementia than mild-to-moderate dementia, but
overall, the phototherapy was no more effective than placebo [66]. Another study focused on the treatment of
sleep-related problems and the potential role of phototherapy, finding the approach
effective for improving the sleep of healthy older people [67]. Another study noted the documented efficacy of phototherapy for
seasonal affective disorder and bipolar depression, but studies including and/or focusing on
older adults are limited.
16 . Which complementary therapy has shown evidence in improving fall risk in older adults?
| A) | | Yoga |
| B) | | Pilates |
| C) | | Tai chi |
| D) | | Swimming |
NONPHARMACOLOGIC TREATMENT OPTIONS
One study sought to compare measures related to fall risk
(e.g., strength, fear of falls, balance, functional mobility) in a group receiving a tai
chi course and a group who did not (i.e., control group) [68]. This study found that the tai chi group
improved in all measures, while the control group did not. The improvements in strength
and ability to perform functional tasks can serve as a potential fall prevention
intervention [68]. This supports the use
of community-based tai chi programs in improving fall-risk measures in older adults. There
is evidence that tai chi is effective in decreasing symptoms of depression and anxiety,
managing stress, and ensuring exercise self-efficacy [10,70].
17 . What percentage of older adults living at home have experienced elder abuse?
Elder abuse is a significant issue in the United States, but
it is often under-reported; nurses play a crucial role in the identification and reporting of
this abuse. An estimated 10% of older adults living at home have experienced elder abuse,
including exploitation and neglect [77].
Having knowledge about the different types of elder abuse can assist nurses and other
healthcare providers in recognizing signs and symptoms. Their vigilance and action are
essential in addressing this problem and ensuring the safety and well-being of older
adults.
18 . Which type of elder abuse is most commonly reported in institutional settings?
| A) | | Sexual abuse |
| B) | | Physical abuse |
| C) | | Financial abuse |
| D) | | Psychological/emotional abuse |
Another study revealed a high prevalence of elder abuse within
institutions [80]. The most reported types of
institutional elder abuse were psychological/emotional (33%), followed by physical (14.1%),
financial (13.8%), neglect (11.6%), and sexual (1.9%) abuse [80].
19 . What is the expected demographic change in the U.S. population by 2050?
| A) | | Decrease in cultural diversity |
| B) | | Increase in cultural diversity |
| C) | | Stable demographic composition |
| D) | | Decrease in minority populations |
International migration, childbearing patterns, and mortality
trends have a significant impact on the cultural diversity of the United States [83]. It is the responsibility of all healthcare
providers to deliver culturally competent care that takes the patient's own self and culture
into consideration; this has been shown to reduce healthcare disparities and improve health
outcomes [83]. The U.S. population is becoming
increasingly diverse, with notable increases projected in African American, Asian, Pacific
Islander, and Native American populations by 2050 [83]. These demographic shifts necessitate an increased ability for nurses and
all healthcare providers to provide culturally competent care. It is crucial, however, for
nurses to engage in personal reflection and confront their own potential implicit and explicit
biases. Implicit bias is defined as attitudes toward a specific social group of which one is
not consciously aware and that could negatively influence care. Acknowledging and addressing
areas of possible implicit bias are important steps to truly providing culturally competent
care.
20 . When working with interpreters, healthcare providers should
| A) | | face the patient while speaking. |
| B) | | face the interpreter while speaking. |
| C) | | let the interpreter lead the conversation. |
| D) | | speak to both interpreter and patient equally. |
One key element of culturally competent care includes using
professional interpreters instead of relying on family or friends ("ad-hoc" interpreters) for
interpretation when caring for a patient with limited English proficiency [84]. When working with an interpreter, it is
important for the provider and the interpreter to face the patient directly, with nurse
addressing the patient directly rather than focusing on the interpreter.
