Do you ever worry about an older adult's mental health? Or wonder if his/her forgetfulness, moodiness, and loss of appetite are normal parts of aging? Are you concerned about a growing dependence on alcohol or drugs to deal with stressful events? It can be difficult to determine whether a noticeable change in disposition is due to external circumstances (e.g., death of a loved one, retirement) or internal health issues (e.g., chronic illness, medication side-effects, depression). Knowing what is a normal part of aging is vital when deciding whether to seek assistance or not.

Moving, talking and thinking a little more slowly are common as the body ages. As the nervous system becomes less efficient, older people often don’t recall facts or respond to stimuli as quickly as they once did. However, persistent memory loss and confusion that interfere with daily life (e.g., wandering or getting lost in familiar surroundings, problems speaking, reading and writing and confusion with names and handling money) are NOT normal parts of aging. These symptoms may be signs of dementia, a medical condition that disrupts the way the brain works. Dementia may be either reversible (i.e., due to nutritional or thyroid imbalance) or irreversible (i.e., due to Alzheimer’s disease, mini-strokes, or alcohol dependence). Only a thorough medical evaluation, which includes a mental status exam, can determine the cause and best treatment. It is estimated that 10 percent of adults ages 65 to74 and nearly half of those over 85 have Alzheimer’s disease or a related dementia.

Before an older adult's mental health deteriorates, gather as much information as possible from a professional. Call a local resource agency such as Mental Health America or the Alzheimer’s Association. Talk with your their physician; they may recommend an office visit or refer you to a geriatric psychiatrist for further testing. In more serious cases, an inpatient hospitalization may be the best course of action. The most important thing is to trust your intuition and seek assistance early. By doing so, you will help them improve their quality of life and overall health and well-being.

Depression

Surveys have shown that a majority of older adults believe it is normal for people to get depressed as they grow older. Depression is NOT a normal part of aging; however, older adults are at an increased risk due to the likelihood of it occurring with other chronic health conditions (e.g., heart disease, stroke, Alzheimer’s, cancer). Also, some medications (e.g., beta blockers) can cause depression as a side effect. Stressful life events (e.g., loss of a loved one or numerous friends, declining health, impaired
mobility, and the loss of freedom associated with these declines) can trigger depression.

Symptoms of depression include persistent sadness, change in eating habits with weight gain or loss, and change in sleeping habits. Given that primary care physicians accurately recognize fewer than one half of patients with depression and that older adults are more likely than any age group to try to handle depression themselves, it is critical for you, as a caregiver to communicate your concerns to their physician. Left untreated, depression is a significant predictor of suicide among older adults, with older white males being particularly vulnerable. However, when recognized and addressed, clinical depression is a very treatable illness.

Contributing factors for depression in older adults are: loss of spouse or other family members, presence of chronic medical conditions, pain, loss of functional independence, frustration with memory loss, and difficulty adapting to changing circumstances.

Dementia

Dealing With The Diagnosis 

Finding out that a loved one has Alzheimer’s disease or another form of dementia can be stressful, frightening, and overwhelming. Once you begin to take stock of the situation, here are some tips that may help:

  • Ask the doctor any and all questions you have about dementia. Find out what treatments might work best to alleviate symptoms or address behavior problems.
  • Contact organizations such as the Alzheimer’s Association and the Alzheimer’s Disease Education and Referral (ADEAR) Center for more information about the disease, treatment options, and caregiving resources. Some community groups may offer classes to teach caregiving, problem-solving and management skills.
  • Find a support group where you can share your feelings and concerns. Members of support groups often have helpful suggestions or know of useful resources based on their own experiences. Online support groups make it possible for caregivers to receive support without having to leave home and outside usual meeting times.
  • Review your day to see if you can develop daily routines that makes things go more smoothly. If there are times of day when the person with dementia is less confused or more cooperative, plan your routine to make the most of those moments. Keep in mind that the way the person functions may change from day to day, so try to be flexible and adapt your routine as needed.
  • Consider using adult day health services or respite services to ease the day-to-day demands of caregiving. These services allow you to have a break, while knowing that the person with dementia is being well cared for.
  • Begin to plan for the future. This may include getting financial and legal documents in order, investigating long-term care options, and determining what services are covered by health insurance and Medicare.

Communication

Trying to communicate with a person who has dementia, particularly Alzheimer’s disease, can be a challenge. Both understanding and being understood will become more and more difficult as the disease progresses.

  • Choose simple words and short sentences and use a gentle, calm tone of voice.
  • Avoid talking to the person with dementia as if they were a child or talking about the person as if they weren’t there.
  • Minimize distractions and noise—such as the television or radio—to help the person focus on what you are saying.
  • Allow enough time for a response. Be careful not to interrupt.
  • If the person with dementia is struggling to find a word or communicate a thought, gently try to provide the word he/she is looking for.
  • Try to frame questions and instructions in a positive way.
  • Be calm and quiet. Avoid using a loud tone of voice. Respect the person’s personal space and don’t get too close.
  • Try to establish eye contact and call the person by name to get his/her attention. Remind the person who you are, if they don't seem to recognize you.
  • If the person is confused, don’t argue. Respond to the feelings you hear being communicated and distract the person to a different topic if necessary.
  • If the person doesn't recognize you, is unkind, or responds angrily, do not takie it personally. He/She is reacting out of confusion. 

 Driving

Making the decision that a person with dementia is no longer safe to drive is difficult, and it needs to be communicated carefully and sensitively. Even though the person may be upset by the loss of independence, safety must be the priority.

  • Look for clues that safe driving is no longer possible, including getting lost in familiar places, driving too fast or too slow, disregarding traffic signs, or getting angry or confused. (for additional tips see Transportation Chapter)
  • Be sensitive to the person’s feelings about losing the ability to drive, but be firm that he/she can no longer do so. Be consistent—don’t allow the person to drive on “good days” but forbid it on “bad days.”
  • Ask the doctor to help if necessary. The person may view the doctor as an “authority” and be more willing to stop driving at their insistence. The doctor also can contact the Department of Motor Vehicles and request that the person be reevaluated.
  • If it comes down to it, take away the car keys. If just having keys is important to the person, substitute a different set of keys.
  • If all else fails, disable the car or move it to a location where the person cannot see it or gain access to it.

Bathing

While some people with dementia don’t mind bathing, for others it is a frightening, confusing experience.

  • Plan the bath or shower for the time of day when the person is most calm and agreeable. Be consistent. Try to develop a routine.
  • Respect the fact that bathing is scary and uncomfortable for some people with dementia. It is also something that previously was a very private activity. Be gentle, respectful, patient, and calm.
  • Tell the person what you are going to do, step by step, and allow him/her to do as much as possible.
  • Prepare in advance. Make sure you have everything you need ready and in the bathroom before beginning. Draw the bath ahead of time.
  • Be sensitive to the temperature. Warm up the room beforehand if necessary and keep extra towels and a robe nearby. Test the water temperature before beginning the bath or shower.
  • Minimize safety risks by using a handheld showerhead, shower bench, grab bars, and nonskid bath mats. Never leave the person alone in the bath or shower.
  • Try a sponge bath. Bathing may not be necessary every day. A sponge bath can be effective between showers or baths.

Dressing

For someone with dementia, getting dressed presents a series of challenges: choosing what to wear, getting some clothes off and other clothes on, and struggling with buttons and zippers. Minimizing the challenges may make a huge difference.

  • Try to have the person get dressed at the same time each day, so he/she will come to expect it as part of the daily routine.
  • Encourage the person to dress him/herself to whatever degree possible. Plan to allow extra time, so there is no pressure to rush.
  • Allow the person to choose from a limited selection of outfits. If he/she has a favorite outfit, consider buying several identical sets.
  • Arrange the clothes in the order they are to be put on to help the person move through the process.
  • Provide clear, step-by-step instructions if the person needs prompting.
  • Choose clothing that is comfortable, easy to get on and off, and easy to care for. Elastic waists and Velcro enclosures minimize struggles with buttons and zippers.
  • Consider how slacks will fit with adult diapers if the older adult is incontinent.

Eating

Eating can be a challenge. Some people with dementia want to eat all the time, while others have to be encouraged to maintain a good diet.

  • View mealtimes as opportunities for social interaction. Try to be patient, to avoid rushing, and to be sensitive to confusion and anxiety.
  • Aim for a quiet, calm, reassuring mealtime atmosphere by limiting noise and other distractions.
  • Maintain familiar mealtime routines, but adapt to the person’s changing dietary needs.
  • Give the person food choices, but limit the number of choices. Try to offer appealing foods that have familiar flavors, varied textures, and different colors.
  • Serve small portions or several small meals throughout the day. Make healthy snacks, finger foods, and shakes available. In the earlier stages of dementia, be aware of the possibility of overeating.
  • Choose dishes and eating tools that promote independence. If the person has trouble using utensils, use a bowl instead of a plate, or offer utensils with large or built-up handles. Use straws or cups with lids to make drinking easier.
  • Strongly encourage the person to drink plenty of fluids throughout the day to avoid dehydation.
  • As the diease progresses, be aware of the increased risk of choking because of chewing and swallowing difficulties. 
  • Maintain routine dental checkups and daily oral health care to keep the mouth and teeth healthy.

Activities

What to do all day? Finding activities that the person with dementia can do, and is interested in, can be a challenge. Building on current skills and interests generally works better than trying to teach something new.

  • Don’t expect too much. Simple activities often are best, especially when they use current abilities.
  • Help the person get started on an activity. Break the activity down into small steps and praise the person for each step he/she completes.
  • Watch for signs of agitation or frustration with an activity. Gently help or distract the person to something else.
  • Incorporate activities the person seems to enjoy into your daily routine and try to do them at a similar time each day.
  • Try to include the older adult with dementia in the entire activity process. For instance, at mealtimes, encourage the person to help prepare the food, set the table, pull out the chairs, or put away the dishes. This can help maintain functional skills, enhance feelings of personal control, and make good use of time.

Take advantage of adult day health services, which provide various activities for the person with dementia, as well as an opportunity for caregivers to gain temporary relief from caregiving. Transportation and meals often are provided.