Essential Skills to Improve Counseling and Caregiving With Seniors

Foreign like to welcome everybody to today's presentation on unique issues in the treatment of seniors. I'm your host, Dr. Donnelly Snipes. Today we will explore unique issues in all pieces of life, physical, interpersonal, emotional, cognitive, environmental and spiritual when working with seniors. And one area that was brought up prior to class that is that were not covered specifically in the PowerPoint that does deserve mention is gray divorce couples coming into counseling that are much older that are on the verge of divorce and trying to figure out what to do about that. And that probably deserves its own PowerPoint and its own class. But I did want to mention that that is one thing that we're not probably going to cover in detail today. That is a significant issue. So physically, older adults a lot of times report that, hey, I only sleep three hours a night or I don't need any more sleep than that. I can't get to sleep. There's a lot of sleep changes. And this is multif factorial. Remember, our circadian rhythms help us get to sleep at a particular time and help us stay asleep. But if the person is under stress and it's going to throw their circadian rhythms out of whack, if they are not maintaining a regular routine where it's light when it's supposed to be up and it's dim or dark when it's time to sleep, if it is too hot when they are trying to get to sleep, or if they're engaging in activities that are energizing or even stressful prior to bed, it's going to be harder to get to sleep. So in looking at the older adults, a lot of older adults will spend a lot of the day sitting inside in the dark, watching tv, what have you. And so they're not on a routine, especially once the person has retired, their circadian rhythms tend to get way out of whack because they don't have those hard sets every day of, okay, I'm at work and it's time to be awake. So we want to help them evaluate that. That will help their sleep a lot. There are other issues like having to get up and pee. Chronic pain, those are two big ones for older adults that may inhibit their quality of sleep. Sleep is so important for cognitive functioning. If we don't get adequate quality sleep and adequate deep sleep, our brain doesn't clear out a chemical called adenosine. And adenosine is what attaches to the receptors our brain that causes us to feel sleepy and kind of tired and foggy. When adenosine doesn't get cleared Out. Guess what? We feel brain fog the rest of the day. We have cognitive difficulties. We tend to be more irritable because our brain perceives sleep deprivation as a threat, as a stressor. So it triggers our stress response. And we're going to talk about stress as we have before as a bucket, and we have, every time we have stress, we add water to that bucket until, until we resolve the stressor. And if you just keep adding water to that bucket, it's going to overflow. People who are older, and we'll get into this in a few minutes for a variety of reasons, as you will see, have a lot of ongoing chronic stress, some of which they can address, some of which they can't. Our goal is to help them empty the bucket out as much as possible so they're not right on the verge of overflowing all the time. That can help with sleep and, and again, sleep and circadian rhythms can help a lot with a lot of things. And even though it's not cognitive, you can help people get better sleep with white. White noise, pink noise, brown noise. They found pink and brown noise are actually really good for sleep. White tends to be really hissy for most people and, and not so relaxing. Encouraging them to keep a sleep routine, encouraging them to turn down the lights two hours before bed, minimize that blue light exposure. That's all very helpful and can help them start getting their body set. Every single cell in our body operates on a circadian clock. Every single system in our body has a circadian rhythm to it. So when our circadian rhythm gets out of whack, everything goes fluy. Chronic pain, a lot of adults have it, a lot of older adults have it. They start getting arthritis or hip pain or stenosis or something else. And it is part of our body kind of wearing out a little bit. It doesn't mean it's time to throw it in the junker. It just means that we have to accept that we are going to have some level of pain sometimes, maybe all the time, and that we can have pain and live our rich and meaningful life to the best of our ability to. Focusing on those days when the pain is better. Maybe somebody has chronic arthritis and osteoarthritis, rheumatoid arthritis, whatever. And some days it's a 2 out of 10. Well, there's still a little bit of pain there, but that's pretty darn good. And some days it's an eight or a nine out of ten. Those are bad days. Appreciating the two days. And instead of Saying, well, I've got some pain and being angry about it. Embracing the fact that hey, I only have really low pain today, so score, I can do things. Encouraging them to work with their doctor and their physical therapist to develop plans to help them manage that pain. Because chronic pain is going to impair sleep, it's going to add stress and it's going to impair mood. And people sense sense of helplessness and hopelessness. A lot of people as they age start feeling like they are just waiting to die. And that's not living a rich and meaningful life. That's heartbreaking. So we want to look at what is going on under the hood that may be contributing to some of this. People who are older naturally have slower recovery. If they are older and active, great, but they are going to have slower recovery. One of the women that I worked with at the animal rescue that I, I volunteer at, she is now almost 80 and she still goes on bicycling vacations and she cycles all over the place. I mean, she's a force to be reckoned with. But it takes her body longer to recover than somebody who was 20. It's just the way it is. When we are 50, 60, 70, we can't do what we could do when we were 20 or 30. Our body is just not capable of it. It doesn't mean we can't do it at all. Doesn't mean we can't run or cycle or go hiking or rock climbing or whatever it is that you like to do that's physical. Doesn't mean you can't do it at all. It just means that you have to be realistic. And I fight that tooth and nail. But I'm starting to learn to accept it. Because when I try to act like I've got a 25 year old's body, I end up getting hurt. And if I try to embrace the fact that, okay, I've got a 55 year old body, then I'm much better at enjoying what I'm doing. I'm like, hey, I'm 55 and I can still do this. Maybe not the, maybe not the way I could when I was 25, but I can still do it and I still enjoy it. And I recognize I'm going to need more recovery time. That's important. When people get sick when they're older, they tend to require more time to recover as well. The body just takes longer to do everything. And helping people develop a sense of acceptance of that is vital to helping them feel empowered to move toward their rich and meaningful Life as opposed to getting angry and grumbly and hopeless. A lot of older adults, and this is another thing that's really important in mental health issues. A lot of older adults have increased UTIs, but as we get older, some of our pain receptors become less sensitive. Who knew, you know, you think with all the arthritis and everything, we'd be firing on all cylinders, but not so much. Apparently, as people get older, a lot of times their urinary tract infections become painless. So when you're younger and you have a uti, you know, you know, you go to the bathroom and it feels like somebody's stabbing you with a knife in the, in the bladder when you're older, apparently it's not the same. 30% of people who present with dementia like symptoms in the emergency room don't have dementia at all. They've got a UTI. UTIs will contribute to increased irritability, increased confusion, increased tearfulness. So we do, if there's a sudden change in the person's behavior, not something that kind of gradually develops over a few, few weeks or months, but there's a sudden change over a couple of days, suspect a UTI and encourage them to do an at home test. It's not like you got to go to the doctor to get it diagnosed. You can do an at home screening and call Teladoc and be like, hey. But getting those taken care of is really important. People with dementia generally don't recognize or don't have the words to express that they've got a urinary tract infection. Even if they feel it, a lot of times it goes undiagnosed. So if you've got somebody who has dementia and they start acting more irritable, more confused, more, more of everything, suddenly suspect a UTI and again, do an at home screening. It doesn't cost that much. And then you can, if it comes up positive, then it's really easy to either go to the doctor or call the Teladoc or whatever you're going to do. And I'm not advertising for Teladoc. That's just the only one I know. But you know, your phone physician. Dehydration going right along with UTIs. If we don't drink enough fluid, we're not keeping everything fluid flowing and lubricated. We can create environments where we get more infections. As we age, our thirst receptors become less sensitive, a lot of things become less sensitive and we become more prone to dehydration. We don't recognize that we're thirsty. 1% dehydration shows notable cognitive slowing in a lot of people, and this is even in younger people. And once a human being of any age gets to 3% dehydration, cognitively, they're actually at the level of someone who is legally drunk. Okay, so older adults, who a lot of them are chronically dehydrated, may have some cognitive symptoms and confusion and maybe even irritability that stems from dehydration. Dehydration can also contribute to orthostatic hypotension, which means they get really dizzy when they stand up, which contributes to falls. Another thing we don't want them to do, because that's a whole other mess that we need to deal with. But again, from a mental health standpoint, UTIs and dehydration can contribute to a lot of cognitive and emotional symptoms. Nutritional changes. As people get older, they can't chew food as well. That when we don't chew food as well, we don't break it down as well. We don't absorb it as well. Older adults that have dry mouth, again, the body is not breaking the food down as well in the mouth, so it's not as available when it gets to the gut. The gut doesn't absorb stuff as well. So there's another humdinger for you. Add to all of that that as we get older, I know our taste buds become less sensitive, especially sweet and salty, which. Those are the two flavors that I love the most. And as we get older, they start going on the fritz. So a lot of older adults don't find food very tasty or palatable. And. And you're like, well, that's a nutritionist issue. Yes, it is, but. But people can't make the hormones and neurotransmitters they need if they're not eating a healthy diet. You don't have the building blocks for serotonin and dopamine. Guess what's going to happen to mood and cognition. It's going to go in the crapper. It is important that we take note of these nutritional issues for many older adults. If they're, if they have poor fitting dentures, again, if they have dry mouth, they. There are things that can be done to address that. If they have gum disease, which is true for young people too, Gum disease increases systemic inflammation and can cause mood issues and. And other problems. But we want to be, pay attention to these. Nutritionally, we can't recommend diets. You know, that's out of our scope. But when the person goes to a dietitian, one of the things the dietitian may recommend is powdered foods. And you're like, oh, that sounds disgusting. Well, think about smoothies. And I have a smoothie every morning. It has a base of kefir, it has broccoli powder, nettle powder, beetroot powder. There's a bunch of different things in it. And it tastes pretty good. You know, I don't mind the taste. It has a lot of cocoa powder in it and it tastes pretty good. And I get a lot of nutrients, not that I can't chew. But for people who have difficulty chewing or swallowing, as dementia progresses, the swallowing reflex also starts to degrade. Smoothies can be helpful. And as opposed to drinking one of those pre made shakes that just has artificial vitamins thrown in there, it can be really helpful for an older adult to kind of be able to experiment. I have, oh, I also use blueberry powder and pomegranate powder. Oh, they're lovely. When you add them to like a vanilla base protein powder it, you can make delicious meals. So again, we can't recommend this, but we know that it is possible for an older adult to find different combinations of foods that are palatable and will help them meet their nutritional needs. Again with the oral health. If they don't have well fitting dentures, good fitting dentures, whatever, they may not chew their food well, which can cause problems. They also may feel self conscious, especially if there feels like their dentures are moving around, which may cause some social withdrawal, which we'll get to in a few minutes. But that's a whole other issue as people get older. Oh, unfortunately, as our gonadal hormones go down, which hormone changes is the next thing. As our gonadal hormones naturally go down, estrogen, testosterone, progesterone, in andropause and menopause, our body perceives that as something of a stressor. Older adults tend to have what we call sympathetic dominance. That means even if they don't have a trauma history, if that's possible, but even if they don't have a trauma history, older adults tend to have a much stronger stress response system, sympathetic nervous system, than parasympathetic. Another one of the best things you can do when working with older older adults, even from a prevention standpoint. Sleep hygiene, managing circadian rhythms and helping them strengthen that parasympathetic nervous system. You can do it really easy with the pulse ox monitors. You don't have to get anything that's super expensive. Put on the pulse ox monitor or go on a walk around their house or the facility or wherever you're at put on the pulse ox monitor, notice what your pulse is, have them sit down and then have them breathe slowly. Focusing on noticing how their heart rate is slowing down by watching the thing. Doing that is usually not triggering for people with trauma histories because they're not doing a body scan, they're not doing an internal focus and they're focusing on the number on the thing. This when we slow our breathing, we slow our heart rate. That's just the way our body responds. Anything they can do to slow their, their breathing, whether it is humming, singing loudly, square breathing. A lot of older adults don't want to can't chew gum, but they can blow bubbles. You know, that bubble stuff that you can get at, you know, any, any store and keep with you so they can just blow random bubbles. Slows your breathing. I put a little, I put a couple of drops of essential oil of catnip in mine and I blow them for my cats. That way I feel like I'm doing something for my cats instead of just for myself. But hormone changes. Estrogen and testosterone are neuroprotective in their respective sexes. As we get older, those go down. That sucks. However, oxytocin is also neuroprotective and anti inflammatory. So even though our estrogen or testosterone have kind of gone into the basement, by increasing oxytocin, we can buffer a lot of the stress that those hormones used to help regulate. So for those people who don't want to go on hormone replacement therapy, oxytocin is one of the ways to do that. That is our bonding and self protection hormone. Encourage people petting animals, having an animal around that can increase oxytocin. Doing nice things for others, that can increase oxytocin. Laughter, Heck, that can increase oxytocin. Even if you're laughing by yourself, doing things in a group, like when people go to worship services and they sing together or chant together, that actually raises oxytocin significantly. Even if you're just, if you're in an ALF or something doing, or if your loved one is older and aging in place, doing something with them can be fun. Playing games, poker, gin rummy, even karaoke, whatever it is they like to do. There's a couple of people at the ALF that I work at that sometimes that love playing the piano. And there are other people that love singing, so they work together. Guess what? They're both having fun increasing oxytocin. So what is it that this person loves doing that's going to help them increase their oxytocin and ultimately it comes down to not necessarily a person or a thing, but, but doing something that helps a person feel connected. If I'm do when I feed my birds and I watch them eat, eat the bird seed from the feeder, I'm raising oxytocin. When people go out and and feed the pigeons or feed the squirrels at the park and enjoy doing that, not only are they getting a hit of endorphins, but they're raising oxytocin. There's a lot we can do. We just need to be creative about it. As we age, we naturally lose our peripheral vision so we can't see as wide, which means that older adults can feel more vulnerable in, especially in busy environments like restaurants or even alfs and things. If they're not at home, if they're not in their room, they can feel more vulnerable because they can't see as much. Effective use in, in the house or in the alf of mirrors so they can see people coming up behind them can help reduce stress. If you are going to a restaurant or something, making sure that the older adult is not sitting in the middle of the aisle where people are walking around behind them all the time, that's distracting at best. Help making sure that they can sit where they have their back to either the somewhere where people aren't going to walk or they're back to a wall can help them feel more comfortable. They also have impaired hearing and vision. So again, restaurants, when people are going out, if you want them to socialize, you know, you're taking grandma out to the restaurant because you want to see her. But if there's a lot of background noise, Grandma may not be able to hear what's going on very well. So asking to be set in a area where there's not as much talking and activity and background noise can be really helpful. If grandma has hearing aids, there are a lot of apps that they can get that they can have the phone set on the table, the phone hears what you say and then it translates it into their or trans sends it to their hearing aid. So that's another way that, another thing that can be helpful. But when people feel vulnerable or when they get frustrated because they can't hear and understand what's going on, it prompts frustration, it prompts stress and irritability and eventually social withdrawal. So we need to examine if grandma has suddenly withdrawn or maybe not so suddenly. What is it that has changed? Why isn't grandma spending time out with everybody like she used to? Now, if grandma never spent time with anybody, then you know, That's a different issue. Maybe Grandma's an introvert. Introvert. Older people have a high fracture risk, which as far as mental health goes, is not something that we're going to focus on a lot, except to recognize that an older adult, especially one that's already had a knee replacement or a hip. Hip fracture, is likely going to be more hyper vigilant because they. They don't want to do that again. Recovery from those things is painful as all get out. And that hypervigilance can make them feel on edge. It takes a lot of energy, and it can make them feel vulnerable in a variety of environments. They may be afraid to get up and go to the bathroom because they're afraid they're going to fall. So remembering that behavior has meaning if there's been a change in behavior. Go back to when the behavior changed, when grandma started retaining urine or retaining her bowels, and figure out what changed. Did she fall? Did she have a urinary tract infection? Did she have a particularly painful bowel movement? Older adults tend to get constipated, so that's something that can happen. But anyway, back to fracture risk, just recognizing it. There are things that people can do. If you call your local area agency on Aging, there are professionals that will go in and evaluate the living environment for trip and fall hazards and make recommendations to make the house as safe as possible. People who are older, and this is another one that's big for mental health. Slower medication clearance. And I've shared with y' all before and many years ago, I think, but I'll share it again. My grandfather was lifelong alcoholic, so his liver didn't work very well anyway. But when he was much older, probably in his 70s, he was struggling with a lot of anxiety and PTSD and stuff. And the doctor prescribed him Valium, prescribed him volume at the level of a person who is a younger adult whose liver is functioning completely well. Well, long story short, Grandpa ended up in a coma in the hospital and because the Valium wasn't clearing his system quickly enough. So it is really important that older adults be cognizant of the medication they're taking and any supplements they're taking, because not all doctors are geriatric specialists. And while you'd like to think that all doctors understand the liver clearance issue, clearly they don't. A lot of older adults are also on multiple medications. Polypharmacy. There are certain enzymes in our body. Cytochrome P450 is one group, one family of enzymes that break down toxins and medications and help Clear them from our body, unfortunately, or whatever. A lot of medications require the same enzymes, so they compete. And one medication, one substance is going to win out, so it's going to get cleared as normal. The other substance is going to sit there and build up in the system because it's waiting for its turn for that enzyme to be available to clear it out of the system. So you may see older adults have significant mood and cognitive changes on medications. You may see them have, even if they're not contraindicated, it's not becoming toxic. Those medications, because of the slower clearance or because of the way they interact with, may impact their mood, it may impact their gut microbiome. It may, for a variety of reasons that, you know, much more in depth presentation on that one could be done. But making sure you're aware of all the medications your older adult person is on, whether it's somebody you're a caregiver for or a patient of yours, is really important. And understanding the impacts, destigmatizing the impacts as well. If the person is having mental, mental fog, brain fog, confusion, making sure to reassure them, assuming they don't have a dementia diagnosis that you know, it could be a side effect to your medication, and encourage them to go back and talk to their doctor. If their confusion started a week after they started taking this medication, pretty good idea that that's contributing. Now the doctor may switch them to something else, may tell them that that'll go away in a while, whatever that's between them and their doctor. But being aware of that can be super helpful in helping people not freak out. Because what happens with older adults when they start having difficulty remembering or finding their words? A lot of them catastrophize and jump to, I'm, I've got dementia. No, no you don't. The vast majority probably don't have dementia. They have normal age related cognitive slowing that is compounded by sleep problems, dehydration, poor nutritional absorption, and maybe polypharmacy. But it's always good. If they have those concerns, refer them to their medical doctor for a full workup because, you know, we can't say, but we can help them recognize that there are other possible explanations. Older adults also tend to have concerns about their physical appearance. As we get older, our base metabolic rate slows just the way it happens. So a lot of older adults put on weight. Maybe not a lot of weight, but some, you know, as my son would say, I'm certainly not at my playing weight anymore, but you know, okay, I've accepted that. I'M not going to get back down to that. Some people may have a lot of difficulty accepting that they may try radical steps in order to manage their weight that are potentially unnecessary. Encouraging them to weigh the risks and the benefits of some of these steps is really important. Sagging skin. Oh, we all hate it. But especially in older women, there tends to be a fear of having sagging skin around the face and people feel very self conscious about it. Helping them work on accepting what's going on or figuring out how to deal with it in a way that's meaningful to them is going to be important because it can become a focus of their attention where they feel like every almost like body dysmorphic disorder. They feel like everybody's staring at their sagging jowls. And hair loss, same thing. They feel their hair thinning, they see their hair thinning, they feel less attractive, which can have significant impacts on their self esteem, especially if a lot of their self esteem has centered around their attractiveness for their life. Interpersonally, retirement is the beginning of older adult changes. When we retire, not only do we lose that circadian sinking that we have with going to work, but, but we also lose the interaction and oxytocin that we derive from doing a job that we enjoy, that we're good at, that helps others. So we have a double whammy with retirement. But a lot of people when they retire, it's a loss that they need to grieve and they need to grieve the fact that they're not going to see those people anymore. And most of the time, no matter how much they say, oh yeah, we'll get together, we'll do this, we'll do that, you don't hear from those people again, or at least not nearly as often as you had hoped. That's been my experience. And the people that I've worked with as well as with myself when I've left jobs, those people are just so, still so busy because they're going to work every day. They don't end up maintaining those connections, encouraging people to figure out how can I nurture the connections that are important to me in my rich and meaningful life? Not everybody's important. So how can I identify the 2, 5, 10 people depending on the person that are really important and what can I do to nurture those relationships so they stay strong? Death, you know, as we age especially, we're going to lose more friends, family and idols. I know it's hard for me when people I grew up with TV stars and singers and blah Blah. You know, suddenly they're dead and I'm like, oh, you know, it's kind of a stark awakening that, you know, I'm headed down that path too. Even though, you know, like Jimmy Buffett, I never met him. I grew up listening to his music and it's a tragedy in my mind that he's gone. But, you know, it was his time. But yeah, it was kind of a stark, stark awakening that, hey, we don't live forever. As we get older, we're also going to start losing our friends and family, our sisters, our brothers, our friends that they're going to die. And every time it happens, not only do we grieve their loss, but a lot of times the older adult will start experiencing anticipatory grief because they know they're getting closer to that point. So it's different than the 20 year old whose grand grandparent dies. Where the 20 year old's like, I've got my life in front of me. The older adult is like, oh, you're not there. But by the grace of God go I. Moves can also cause older adults to lose friends and become more lonely. If they have to move in with their kids because they can't live independently anymore or they have to move to an alf, they're not around their neighbors, they're not in their environment anymore, they may be leaving the house that they raised their kids in, and that may cause them to feel very lonely and isolated. Figuring out how to help them connect to other people and stay connected with those who are important, even if it is only via, you know, like Amazon, Echo video chat or something, can be very helpful. And losing friends to dementia is also terrifying for, for a lot of people, when they see someone that they have grown close to and they watch the cognitive decline, it is heart wrenching. And a lot of times you'll see people who don't have dementia start distancing themselves from the person who has dementia when they start seeing those symptoms come out. It's sort of a natural, protective, I don't want to hurt that bad when that person finally doesn't remember me. We see the same thing in family members a lot of times, distancing themselves because it hurts so much on the days that they visit mom or grandma and mom or grandma doesn't remember who they are. But as we see our loved ones or our friends succumb to dementia and they're not gone in body, they're just gone in mind. They don't remember us, they don't remember who they are. Sometimes Sometimes it can be devastating. And helping people, again, grieve that loss. A lot of older adults, because they have difficulty hearing and because they have slower cognitive processing, will also withdraw from others. Not. Not out of grief, but. But because it is too freaking hard to be around other people. It takes too much focus and cognitive energy to try to hear and understand what they're saying. And sometimes people talk too quickly. As we age, not only do our sensory responses slow, so if somebody touches you, it takes your brain a millisecond more to register that they're touching you. Same thing when people talk to older adults. You've got to slow it down, give them a chance to hear it, take it in, process it. It's not dementia necessarily, but it is cognitive slowing. It takes us a little bit longer. It's not anything to get freaked out about. But it is important for those of us who are interacting with older adults to be patient. If you're working with older adults in a group setting, make sure that group setting is appropriate for their cognitive processing speed. If you've got them in there with nine other people who are all in their early 20s, then it's probably going to go too fast and that person's going to have difficulty keeping up. So we do need to be sensitive to the slower cognitive processing. Older adults do respond well to support groups, as long as they are at a comfortable pace and the older adult can hear what's going on. So it's important in those support groups to make sure that there's not a lot of background noise and you're not having it in this big cafeteria where there's a lot of echoes and the acoustics just are awful. As we age, we lose independence and personal power, more or less depending on the person. But if you get to the point where you need help going to the bathroom or you have difficulty walking from one end of the house to the other, then it's another thing that's going to be grieved. But we do want to try to help people feel independent and empowered as much as possible. So what can we do to help Grandma? Or help this older adult feel as independent as possible so they don't feel like they're relying on other people to do everything for them? They can't drive anymore. Okay, well, the beauty of it now is that we've got Uber, we've got grocery delivery, we've got Amazon, we've got other things. There are very few things you actually have to leave the house for. So if somebody can't drive, no biggie my son and apparently a lot of millennials. Now he says it's common among people his age are actually having their groceries and stuff delivered so they can focus on doing their work and they find it more cost effective and expeditious, whatever. So it's not admitting weakness by having groceries delivered. It's practical for a lot of people. And that also makes sure that if grandma wants that or specific orange soda that you can only get at that one grocery store. Okay, well, nobody has to run across town to get it. It can be delivered. Hallelujah. Same thing is true with like denture creams and stuff. Sometimes there are things that they really need. Places like Walgreens and Walmart often have like two hour delivery if you really need it. Transference. This is a unique one for counselors and care workers working with older adults. Many older adults will see you as their child, their grand or their grandchild. So they have a hard time. They're 80 and you're 30. They have a hard time seeing you in the role of a, of an expert, in the role of somebody who could give them advice. Sometimes because you are younger now, a lot of them will politely listen, but there can be some dynamics that really echo that of like they're working with their grandchildren or their child not working with their therapist. So we do want to pay attention for those transference issues. If they have a bad relationship with their child, then that also might complicate the relationship between you two. Or they might see you as a younger version of themselves. And when you are you, you're giving them your best counseling stuff and they're like, oh honey, you know, when I was your age, you know, so they're seeing you as a younger version of themselves and as ignorant or foolhardy as they were at that age themselves. So again, it may make it more difficult to develop rapport. Doesn't mean it's impossible. But we do need to be cognizant of twinges of or hints that they might not be seeing us for who we are, that there's some transference going on. Older adults tend to have less filter. Well, we all know that, so I don't need to explain that one. And that's okay. As people working with older adults, we need to be prepared for them to say what's on their mind for those who choose to. Now, some are go the opposite direction and clam up and they develop white coat syndrome. But if somebody has less filter, as long as it's not hateful or derogatory, being prepared for them to just come out with something and you're like, oh, didn't expect you to say that. Disinhibition and sexualization is another issue, especially for older adults with dementia. Even early stages of dementia, one of the first areas of inhibition to go is often sexual inhibition. So older adults may, with dementia, may become more sexually disinhibited. It doesn't mean they're trying to assault or insult you in any way. They don't understand. And there are strategies that you can take to address the issue, but recognizing that you can correct it today, which is Wednesday. But if you go back to see them on Friday, they may not remember what happened on Wednesday. So being patient with them and understanding that they're not trying to be. And not understanding that they're inappropriate in many cases, and which kind of feeds into. I didn't know what to call it besides interpersonal language. It's a cultural issue. One of the counselors that I supervised that was working in an ALF really struggled. She felt like she was being sexually harassed by residents, male residents, because they were calling her sweetie and honey and, you know, telling her how pretty she was. And from their period of time, that was a very. Those were very appropriate things to say. They were trying to be nice or they were interacting through the lens of their culture. They didn't recognize that it was offensive to her. And you've got to figure out as a clinician or as a caregiver, is this a battle that's worth fighting? Knowing that the person is not trying to be inappropriate? Is this a battle that's worth having with this individual? Is it going to do more to harm the relationship, to address it? Only you can make that call. Counseling is often stigmatized by older adults, and hopefully, you know, the next generation of next generation adults will not feel as stigmatized by counseling. But currently, the people who are in their mid-50s and older often still see counseling as a problem. They see it as saying that they are mentally ill or they're crazy. So one of the things that I found works really well with older adults is to engage them on an issue that is meaningful. If they are having chronic pain, well, it's likely due to stress. But instead of saying, join my stress management group, I'll say, let's join my pain management group. Let's talk about ways to manage your pain. If they are having difficulty sleeping again, a lot of times they are ready to glob on to things that address their, their somatic symptoms. That's fine. We're going to get to the same place. In the long run, we're going to use the same tools in many cases. In the long run, we're just addressing it from a different angle. But you're going to get a lot more buy in because that's something they want to go away. If they're, if they've got chronic pain and they're depressed, saying, join my depression group, probably not going to go very far because they're. A lot of their depression is caused by feeling chronic pain and disrupted sleep. So, okay, that's fine. Let's address that chronic pain emotionally. As I mentioned earlier, older adults are almost universally struggling with sympathetic dominance. Strengthening that parasympathetic nervous system can be huge if they're willing to do tai chi or yoga, Even seated tai chi and seated yoga. That is amazing. Not everybody's willing to do that. Okie dokie, let's find another way. What else can help you down? Regulate when your heart rate goes up for whatever reason because you walked around the block because you just had an argument with somebody, for whatever reason, your heart rate's up here. What can you do to bring it back down? Some people will see it as a game, which is really awesome. They'll pop on their pulse ox monitor and it's a game to them to see how quickly they can bring their heart rate back down. Cool beans. There's a lot of death anxiety, as I mentioned. As they get older, they see people that they knew dying, they see people that they knew developing dementia. They know it's coming. You know, it's just. You've seen the actuarial tables. You know you're going to die eventually. But the closer it gets, the more some people start struggling with death anxiety. And helping them process that can be a challenge, especially if they don't know what happens when they die. Nobody knows what happens when we die, really. So we're helping them figure out where they can find good guidance or consolation. A lot of older adults turn to spirituality of some sort. Not necessarily religion, but spirituality. Health anxiety is another thing we see in some older adults. It's like every time they get a new ache or pain or something, they're like, oh, this is it. This is the big one. I've got cancer, I've got dementia, I've got this, I've got that. Because we're constantly talking about that. That's what we hear about on television. That's what we see thrown in our face on Twitter and Facebook and all those places that, you know, this is how you can Treat your dementia or prevent this or whatever. We're not really flooded with information about, hey, you're doing great, that's awesome, because that doesn't sell product. So there is a lot of health anxiety in our culture and as we get older, we have things go wrong more quickly or more, more often. It just happens. Doesn't mean it's a big deal. It just is what it is. Helping people develop a cognitive response to this, acknowledging their fear and then focusing on fitcat. The facts in this concept at this time or the other mnemonic, which is shorter is feel the facts. Any exceptions to the rule? So I have this pain, you know, maybe I've. Maybe I'm having, you know, gallbladder problems. Okay, maybe you are. What are exceptions? When do you not have that pain? Explanations? What are some alternate explanations for why this might be happening? Oh, you just ate three bowls of three alarm chili. I'm not surprised you got a stomachache. And then L stands for likelihood. What is the likelihood that based on the facts and any other alternate explanations that you have, what is the likelihood that this is the big one, Whatever the big one happens to be for them. So feel facts, explanations, exceptions and likelihood. Anticipatory anxiety, anticipating. And, and this is true for caregivers as well as for older adults, anticipating what may happen. You know, I saw my parents and my grandparents all die of cancer. And so there's a part of me that sort of anticipates that, but I've got to keep that in check. Is it worth using my energy to worry about something that hasn't even happened yet or use my energy to nurture the things that are important in my rich and meaningful life and doing what I can to prevent that from ever happening. And I focus on empowerment and prevention myself. But anticipatory anxiety is real. If they've seen others go through it, whatever it is, and they think that there's a chance that they may go through it themsell then we need to address it. And again, feel, what are the facts? What are the exceptions? What are alternate explanations? And what's the likelihood that this is actually going to happen and it's going to be catastrophic? You know, they've come a long way in cancer treatments over the past 20 years. So could I get cancer? I hope not, but I could. What's the likelihood that even if I do get cancer, I'm going to die from it? Okay, so helping people really put it into a cognitive perspective. But in order to do that, they have to get into their wise Mind, which means they've got to down, regulate, turn off, turn, turn down at least that stress response so they can think clearly. When we're in fight or flight, we're not thinking clearly. We disengage from our thinking mind grief and anticipate grief and anticipatory grief. I have a video that's called the Trauma of Aging that goes through all of the losses or a lot of the losses that we experience as we age. There's a lot to grieve and moving to that point of acceptance and embracing what you can do to continue to move toward a rich and meaningful life is huge for a lot of people. Older adults struggle with guilt. There's a huge feeling of guilt, especially as people's independence wanes a little bit. They can't drive as well. Maybe they can't drive at night. You know, things happen. They start to feel like a burden on others. If they start needing the assistance of other people and really processing that with them to identify whether they feel like a burden, okay, that's a valid feeling. Does the other person feel like you are being a burden? Mind reading, assuming that they think I'm being a burden can really put us in a bad space. A lot of times our caregivers, you know, the people who help us out are happy to help us out and we're not being a burden, or they understand and they're willing to do it and, and they're not holding it against us. But we need to encourage the older adult to get out of that mind reading and really check the facts, talk with the other person about, is this a burden? You know, what can we do to make it less burdensome? So everybody's being open and honest about their feelings. And then there's the shoulders. Erickson says this is the time of generativity or stagnation. We look back over our life and we decide. We figure out whether we accomplished what we wanted to set out to accomplish. And if we didn't, then there's regrets. I should have done this when my kids were little. I should have done this with my job. Well, we didn't. We can't rewrite time. So again, there's a grieving process, but there's also examining the what you did do, what things did you do. You don't negate their grief over the things that they didn't do, but expand their vision to what they also did. And, and that can be helpful to regain some balance. Older adults often experience periods of hopelessness and helplessness, especially if they fall ill. Or, you know, they have a rash of people that pass away grief. Huge. And depression can be organic as well. Cognitively, we already talked about this, so I'm not going to belabor it, but our cognitive processing speed slows as we get older. It's not dementia necessarily. Often it is not. So we need to slow down. When we're talking to older adults, when we are in interacting with them in session, we may say something, give them the time they need to hear it, understand it, process it, and respond before jumping in. Encourage their supporters to also do the same thing. Memory impairments are very common as we get older. Encourage older adults. Instead of fighting it, write things down. You know, don't expect yourself to remember everything. If you try to remember everything, that adds more stress. More stress means you're more likely to forget. So just write it down. And they may have. Because they're in parasympathetic or because they've got sympathetic dominance, they may have difficulty with problem solving and rigid thinking because they can't disengage from the way it's always been done to get into their wise mind. Because they're. They're frustrated. They're angry that this isn't working. Environmentally, older adults experience reduced mobility, so helping them figure out what they can do to do the things that are important in their rich and meaningful life. That may mean rearranging the kitchen. That may mean adding grab bars. I don't know what it means, but what can we do to help you stay as independent as long as possible? They may have concern about housing stability if their rent's going up, but their Social Security is not. We want to make sure they know that they're always going to have a roof over their head if they've lost their driver's license. Again, beautiful thing about home delivery and Uber, which we didn't have 40 years ago, that they can use if they don't have a driver's license. In order to help them get not only to places they need to go, like the doctor, but places they want to go like the movies or bingo or a friend's house. There may be safety concerns regarding them cooking at home. There are devices that can be attached to their stove that will automatically turn the stove off after a certain period of time. Same thing for the oven. Now, as far as mental health goes, we're trying to help the person feel empowered and feel safe and feel able to move toward their rich and meaningful life for as long as possible. They may fear that they're going to be involuntarily put in an assisted living facility. So we need to open the lines of communication between them and their caregivers or supporters to define what, under what conditions would you have to be put in an alf? They may have frequent reminders of their aging. Like I said, sometimes you turn on the TV and three people that you grew up watching on TV or listening to their songs, they all died. And it's like, oh my gosh. Just recognizing those are triggers for anticipatory grief and difficulty navigating in a digital world. Not only because they don't know how to work the 16 buttons on their remote or their iPhone or whatever, but also because they don't have the dexterity to push those little buttons and they may not have the vision. A lot of devices have options for bigger text, bigger buttons, etc and voice control if they are not able to do it on their own. And spirituality. Spirituality is not religion. It's a multi dimensional search for meaning and connection to something larger than oneself that can be found through a sense of connectedness both vertically to a higher power and horizontally to others and nature. And that's that connection I was talking about earlier. People do tend, research shows, to become more spiritual as they age, see, seeking a sense of relatedness and connectedness. And spirituality has been found to buffer anxiety and depression and improve health outcomes through the provision of hope and acceptance. Older adults are obviously in a different phase of life and dealing with different issues than younger adults. Older adults respond well to support groups in that are conducive to their slower processing speed. So give them a second having, you know, having them in a group of young people and playing a game like trivial like, oh gosh, what is it where you have to answer first? What's the show that Alex Trebek hosted? I can't even think of it. Jeopardy. Playing a game like Jeopardy is really hard for the older adult because they just their response time is not that fast. We want to treat the older adult and pay special attention to all pieces of life and how aging has impacted those and the person's sense of safety and empowerment and purpose. We can't reverse aging or turn back the clock, but we can help people define and work toward a new vision of their rich and meaningful life.