Mental Health and the Elderly 12 Key Points

Foreign. The 2021 Wellness Retreat is an opportunity for clinicians and non clinicians to enjoy fall in Tennessee and maybe even a leaf change while you take a deep dive into learning about the mind, body connection and strategies for improving your overall well being. Up to 21 CEUs will be available for clinicians, but again, you don't need to be a clinician to attend. The retreat is being held October 20th through 23rd at Cumberland Mountain State park and is limited to 60 people to allow me to have plenty of time to interact with everyone. Go to allce.comwellness to see the detailed schedule and download the registration form. I look forward to seeing you to welcome everybody, today's presentation on mental health and the elderly 12 key points I'm your host, Dr. Donnelly Snipes. We're obviously going to review 12 key issues that either differ or often go overlooked in people over the age of 65. Now, 65 is one of those kind of arbitrary numbers. We can start seeing some dementia conditions as early as the mid-40s for some people. We can also see some cognitive decline and some other issues in people who are younger who have kidney and, and or liver dysfunction. So we don't want to just limit it to 65. But that's your general rule that people often use when they cross over and they start calling it ge geriatric care. Let's talk first about some of the psychosocial issues for adjusting to aging. And there are multiple. You have your existential issues. People, as they age, they get to a certain place and looking back over their life and they either look back over their life and they're like, yeah, you know, this is, this has been quite a ride. I've enjoyed it. I've done the things that I wanted to do. Or they look back with despair and regret. So obviously the first one, great. The if they're struggling with despair and regret, we need to help them explore how to deal with those things. You know, they can't go back and go back through high school again or relive their twenties. That's, that's done. However, what can they do to make the most of the time that they have left to create a rich and meaningful life? Also, when they're looking back, yes, they may not have done the things that they thought they, quote, should do or were going to do, but what did they do? What positive contributions did they make? So encourage them to embrace the dialectics, the the both. And you know, I didn't accomplish some things, but I did accomplish others that I had no Anticipation of doing. As we get older, we lose physical functioning. Whether you like it or not, it happens, and it happens to just about everybody. Even my grandfather, he ran. He was an avid runner, and he ran five miles a day every day until he couldn't run anymore. And then he walked five miles a day every day until he was hospitalized with congestive heart failure. So he kind of pushed it up to the end, but he did have to recognize at a certain point that he couldn't run anymore. His joints weren't taking it anymore, and that was very frustrating for him. And I think a lot of us have experienced the same thing. Once you get into your 30s, sometimes healing takes a little bit longer. It feels like 40s, 50s. You see different changes, and part of that is just the body taking longer to repair itself. You know, think of your body like a machine or like a car. You know, as parts start to get older, you know, you have to treat them a little bit more gingerly, and that can be exasperating to people. And. And sometimes we have to help people deal with their grief surrounding that, their grief. My. My stepfather, for example, gosh, I think it was about the time he hit his past the 80 mark, and he played golf every single day, you know, through his retirement. He was an avid golfer. They lived on a golf course. And right after he turned 80, he started having low back problems and problems with his balance, and he was actually sidelined from golfing for a while, which is one of his main sources of stress relief. So not only was he not able to release. Release his normal stress quote, unquote, but he also had this other issue of having to accept that his body was aging and he wasn't able to do things the way he used to do. Now, thankfully, with some physical therapy and everything, he was able to go back and start, you know, playing nine holes. And I think we've talked about this before. He wasn't able to walk the course anymore with his clothes, clubs, but he had to use it, one of the little golf carts. But he was able to start getting back out there. My grandmother, same sort of thing. She was adamant she was going to live in their house until, you know, she was no longer on this earth. But unfortunately, her physical functioning started to decline. She started becoming more prone to falls and, and other things. And her hearing, which was. She was always deaf in one ear, and her hearing in the other ear started going. So at a certain point, she had to start making adjustments. Death of friends as, you know, even as an adult, you know, we Most of us have lost some friends. But as you get older, people start seeing more and more of their friends and icons from when they were in their youth passing away. And this can remind them of their existential nature or whatever. It can remind them that they're going to die at some point. And this is something that people have to cope with. Not only do they have to cope with the fact that, okay, you know, it's a reality, I am not going to be on this earth forever. But as their friends pass away, their social circle shrinks and it's important to encourage them to keep connecting with people and not withdraw because the pain of loss is too great. So there are a lot of issues around death of friends, but there's also, as I mentioned, some issues surrounding deaths of icons. My, my stepfather, I'll use him a lot because he's a, he's an older gentleman now. He's, he's almost 90. And he was in journalism for his entire career. So he worked with Tom Brokaw, he worked with, I can't even call their names right now, but those famous newscasters from the 50s and 60s he worked with. And as people pass on, you know, he's like seeing the changes and he's recognizing that the people that he worked with are gone. The life that he knew, journalism as he knew it, was gone. So there are a lot of changes. And there's also changes in social relationships, changes in, not partly because of loss. You know, you may not be able to engage with others that, that have either had to move away or they have develop some sort of cognitive dysfunction so they don't recognize you. But there's also changes in what people do because their bodies are changing, their interests may be changing, they may not be able to stay out until 2, 3 in the morning part doing the party scene anymore. They are going to change into doing potentially different things. Now this isn't always the case. One woman I work with who runs one of the animal rescues, she is almost 80 now and she is an avid cyclist. I mean you would think she was just looking at her, you would think she was in her early 60s at most because she is spry as all get out and the things that she always enjoyed doing, she's still able to do, but, but to a lesser intensity, to a lesser degree. She's not going on 100 mile bike rides now. She's going on, on shorter excursions, frequent mental distress or fmd. Yes, it's actually a syndrome, if you will. It's not in the dsm. But it's something that is recognized by people who work with an older population. Frequent mental distress may interfere with major life activities such as eating well, maintaining a household, working or sustaining personal relationships. Older adults with FMD were more likely to engage in behaviors that contribute to poor health, such as smoking, sedentariness and eating a diet that is not super healthy. Very few fruits and vegetables. Let's think about this. When people are going through all of these issues, when they're experiencing anxiety, when they're experiencing depression, when they're experiencing potentially PTSD after a stroke or a heart attack or something, some people do end up developing post traumatic issues, then it, it's important to recognize that that alters the neurochemistry, that alters the HPA axis. Distress, anxiety, anger. Depression tends to contribute to inflammation. Inflammation tends to contribute to more distress, especially depression. And it can contribute to cognitive decline and reduced energy. So people who are experiencing distress are often experiencing not only cognitive things. You know, their thoughts, their feeling helpless and hopeless, perceptions, you know, lots of things going on with that, but they are also having the physiological issues that result from that HPA axis activation. So it's important to recognize the stressors that impact people who are older. You may think, well, they're older, they're retired. What do they have to stress about? Well, a lot. There actually is a lot. So it's important to take a step back and be sensitive and empathetic. Mood issues are not bold under underscore. I should have italicized it too. Mood issues are not a consequence of normal aging. Expecting somebody to become depressed as they get older is not realist, not should not be expected. People will go through episodes of depression and grief when they lose people or things change like everybody else. However, clinical depression, generalized anxiety, ptsd, these are not things that we should expect are a direct consequence of aging. What can cause them? Well, depression can be caused situationally by grief or by life transitions. When people have to go from independent living to assisted living, for example, when they have a significant other pass away, there are a lot of situations that can contribute to depression and grief. Okay, so we want to be cognizant of those things. And we've talked, we talked about some of those on the last slide. Vascularly, there's a bi directional association between depression and cardiovascular disease. If you remember from the blood pressure presentation last week, 45% of Americans have hypertension. So 45% of Americans are at risk for cardiovascular disease and problems with oxygenation and increased inflammation in the, in the body. We see with high blood pressure, we often see increased inflammation. With depression, we see increased inflammation with depression. Depression tends to worsen cardiovascular disease and blood pressure issues and blood pressure issues and cardiovascular disease worsen depression. It's important that if you're working with an older adult, that their cardiovascular health be assessed. You know, they need to be going and getting their annual checkups and their blood pressure work, and if they're not feeling well, encouraging them to maybe get a home blood pressure monitor to keep a log of their blood pressure for a week or two, and if it seems high or if it seems low, to contact their doctor about it. Because it's really for their mood, for their balance for a lot, and for their cognition. It's important for their cardiovascular system to be functioning as optimally as possible. Unfortunately, elderly men have the highest rate of suicide of any group. So we do want to pay attention. If we have an older man who is starting to feel depressed now, that doesn't mean we don't want to pay attention when other people express suicidal ideation. Of course you want to pay attention, but you do want to recognize that elderly men tend to have a much higher rate of actually actual completed suicide when untreated. Depression reduces life expectancy, worsens medical illnesses, enhances healthcare costs, and is the primary cause of suicide among older people, the foundation of depression, apathy, hopelessness, and helplessness. So we need to explore that, identify what is prompting this depression. You know, what, what is triggering it, and it could be physiological, psychological, environmental, or interpersonal. We need to look at all those different areas to identify, okay, what triggered this episode? What is maintaining this depression? What is maintaining your sense of hopelessness and helplessness. Sometimes with older people, unfortunately, a lot of older people are on a lot of meds, and the meds can actually contribute to depression. Looking back with the person looking retro, retroactively and saying, before you felt depressed, what was different or what has changed that prompted your depression? And, you know, total side, not related to elderly people. But I just got new flea and tick collars for our dogs, and two of our dogs seem to have had a very bad reaction to those flea collars. You know, they've worn flea collars before, but this particular time, this particular brand, they don't. It seems to be toxic to them in some way. And, you know, my. My boxer is lethargic. His appetite is kind of gone. And my husband noticed that those symptoms started like 24 hours after he started wearing the collar. So we took the collar off, and we're going to see where we Go from there. If, if it was the collar or not. Now, obviously older adults aren't going to wear flea collars. My point being, if they start a particular medication that may contribute, if they are going through a grieving period and their nutrition is poor and they lose a lot of weight or they gain a lot of weight, that could also mean that their meds, thyroid meds, blood pressure meds, those things may need to be adjusted. So it's always important to explore the biopsychosocial determinants of this person's mood. Both exercise and dietary interventions can promote mental health in older adults. Encouraging exercise not only stimulates the endogenous endorphins, it also stimulates the endogenous cannabinoid system and encourages oxygenation and the release of serotonin. There's a lot of good things with exercise for older adults, just like for anybody else. You know, start slow, you know, encourage them to do a little bit. We don't want them to do something and then wake up in pain the next morning. Consult with their doctor and about anything that, you know, they can do or should do. And. But a lot of times physicians for older adults will recommend, recommend water aerobics, swimming, easy cycling, especially on a stationary bike. Check with your local mall. If you have indoor malls where you are still in Gainesville, Florida, our mall used to open at 6am so people could go in and walk in a safe environment. Now, obviously the stores were closed, but people were able to power walk through the mall. So a lot of older adults tended to use that as a safe place to exercise. And they would also, by virtue of all being there at the same time, would end up garnering social support. As far as dietary interventions, that's outside the scope of most of our practice. But it is important to recognize that what goes in is used to make all of the hormones and neurotransmitters and everything. So if you're not getting all the raw materials in, if you're not getting all the supplies to make what you need, then the system's going to break down. Almost half of older adults who are diagnosed with a major depression also meet the criteria for generalized anxiety. Let that sink in for a second. We don't want to just stop at depression. We want to say what's prompting this depression. Almost half of those adults may have such high levels of anxiety that they have and chronic anxiety that they've prompted some HPA axis dysregulation. So now they have that hypocortisolism. They have a, that Flat apathetic feeling. A lot of times because their HPA axis is not as responsive anymore. It was, it's holding on to stuff. It's, it's stopping response in order to try to protect the brain. We do want to recognize that because treatment for the underlying anxiety, treatment for what's causing the depression and causing the HPA axis activate activation. Come to BetterHelp every day looking for a counselor. BetterHelp makes it easy for you to move your practice online and focus on what you love most, helping others. Better Help's easy to use platform, takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18,000 therapists at better Help helping to improve people's mental health and lives. So let's talk for a minute about normal aging because as I've said multiple times already, things happen as we get older and they're not necessarily pathological. Occasional forgetfulness. Try using notes as reminders as we get older. Sometimes it takes longer to process. Now I'm not talking a minute, two minutes, but I'm, you know, it takes us a little bit longer to hear and process information. That's just a fact of life. Now people who remain engaged and play games and, or play music and do things that keep their brain working, working, that processing stays a little bit faster. People who are isolated, who sit at home by themselves, watch TV all day, their cognitive processing slows a lot more quickly. It may take increased time for complex tasks because everything just goes a little bit slower. They're able to follow written and verbal directions. So that's normal aging. If people can't follow these things, then, you know, we want to be a little bit concerned. My grandmother, you know, was always very independent and, you know, just spry as I'll get out. But as she got older, she started especially once she, you know, was in her upper 70s, she started getting confused very easily. And she did get to the point where she couldn't follow written or verbal instructions. She'd start doing something and forget where she was and then get all flustered. So we do want to pay attention to those things. It takes longer to learn new information as we age, give people time because they're processing a little bit more slowly, which is another issue. If you have groups. For example, when I used to work in residential, we would have groups that were very homogenous or heterogeneous and we would have 20 year olds and we would have 70 year olds in group. And at that point I didn't recognize the need the, the cognitive processing speed differences. So I think the people who were older that were in my group may not have gotten as much out of it because we were going at a faster pace. So it is important to check for understanding. Slow down a little bit if you've got older people in your group. People as we age may have difficulty finding the right word. You know, we've, we've spoken millions of words and sometimes it's just trying to find that name or that word that we're thinking of can be a little bit more difficult. And I, I've noticed that in myself over, over the years. Slowed reaction time, that's another issue you want to be aware of, especially for falls. For example, when you're younger you have a faster reaction time and you can brace yourself for a fall when you. Whereas older people sometimes aren't able to react as quickly and they lose their balance or they fall and they don't break their fall effectively, which results in much more severe injuries. Now, people who are aging are still able to complete their activities of daily living. If people start being, come becoming unable to complete activities of daily living, that's an indication of that that needs to be assessed. And it could be because of physical ailments, could be because of cognitive issues. But it's important to note when that happens. Generally when people are unable to complete three or more activities of daily living on their own, they start qualifying for some level of assisted care, especially if they've got long term care insurance. It's important if they're on Medicare and Med and or Medicaid to check with the state's policies to find out what they can qualify for. For example, in Florida, Medicare will provide for short term in home assistance for people like after they have their hip replaced if they are unable to complete their ADL's without assistance. So it isn't important to know what the older person is, has access to. And as we get older we tend to have more issues with balance. Partly because our reaction time is slower, partly potentially because our blood pressure may be a little bit different. There's a lot of reasons, but if a person starts having significant issues with balance, it's important to have them assessed by a neurologist as we age. Regardless of if you have, you know, other confounding conditions, it's important to recognize that balance can become an issue. And put in guardrails or hold hold bars, grab bars in the bathroom, you know, next to the commode and in the, in the shower, make sure that they're all of the rugs are taped to the floor so somebody can't, you know, scuff them up and trip over a corner, you know, look around. And there are a lot of checklists that are out there a lot of times by hospice facilities. But I also, I have several of videos on case management and case management assessment, needs assessments on the YouTube channel. If you are either living with an older adult, have a love, older adult, loved one that you concerned about, or if you work with the older adult population, having those checklists and handy so people know what they probably should do in order to make sure that they or their loved ones stay safe can be really helpful and comforting in terms of dementia. Cognitive and sensory changes, memory loss and this is generally significant memory loss. A lot of people with dementia will have long term memory. They can remember things that happened five years ago, but they may not remember what happened five days ago. And so when you. One approach called reminiscence therapy that has been shown to improve the mood as well as to decrease agitation in a lot of people with dementia involves I taking pictures or trinkets or some, some sort of memory trigger from the person's past. It can be music or a television show from the person's past and you know, letting them experience that because a lot of times that will bring back those historical memories and obviously you want to bring back memories from a pleasant time in their past. But that can help them be in a moment that is calming and reassuring and happy for them, even though it's not the present moment, so to speak, and it can reduce their agitation. They may have difficulty in communication, especially finding the right words to communicate or keeping track of a conversation. Normally our, our processing slows, you know, that's, you know, totally expected. But if people really start having a lot of difficulty communicating and it's frequent or they get lost frequently in conversations, especially one on one conversations, then it needs to be assessed to identify any signs of dementia or Alzheimer's or, or other cognitive issues that there are medications and there are treatments that can slow the progression. If they have a reduced ability to organize, plan, reason or solve problems, or difficulty handling complex tasks, or even confusion and disorientation such as getting lost in familiar places. Maybe they forget how to get to the bathroom in your house when they're visiting or something. Those are all signs that someone may need a neurological evaluation if they have difficulty with coordination and motor functions more than just, you know, being a little bit, having a little bit less balance and having slower reaction times. But if they have Start having a lot of difficulty feeding themselves, washing, holding a glass. Definitely get them evaluated. They may have loss or reduced visual perception, a metallic taste in their mouth, a decreased sense of smell, or agnosia, which is the loss of ability to recognize objects, person sounds, shapes or smells, even though that sensory organ is not defective. So they may see something and their eyesight is fine, but they can't identify what it is. Those are all indications that the person probably needs to be evaluated. Now, when people start having difficulty with daily activities of daily living, like Gwen points out, a lot of times when older people fall, they may not tell anybody because they're afraid they're going to be moved into assisted living. It's important to talk with the older adults in our, in our family that we care about and let them know, you know, if you fall, you know, there are things that we can do to help you out. You know, we're not going to, we're going to do whatever we can to try to help you stay as independent as possible for as long as possible. But it's important to let us know. I know my grandmother fell a couple of times and she had like huge bruises up, you know, all the way up her thigh from falling in the bathroom. And it's important again to be honest with them, but also let them know there are things that can be done. You know, we can put, we can install grab bars and things, but we need to know when people start having cognitive and sensory changes, if they start losing hearing, if they start having other problems. They also may not tell people because they're afraid, number one. Number two, they may be afraid of being sent to in assisted living. They may not be sure exactly what's going on or have an ability to communicate it. And all of this can lead to withdrawal. Withdrawal and isolation is one of the key factors that we're going to talk about. One of the key preventable factors for dementia, psychological changes in people with dementia, changes in personality or behavior, significant sudden changes, depression, anxiety, hallucinations, mood swings, agitation, especially with changes in routine, apathy, isolation and withdrawal. Now, obviously, some of these are characteristics of depression and even depression with psychotic features. So it's important to have an accurate and thorough cognitive and psychological assessment. But if you see any of these symptoms, any of these symptoms indicate that there's somebody that's really struggling. So something needs to be done. And figuring out what's causing it is usually the beginning. Authors estimate that as much as 35% of dementia cases could be prevented by targeting 10 modifiable risk factors, wow, 35%. So what are they? Early life education. And they're not sure exactly why that is protective. They hypothesize that people who have early life education tend to go on to be of higher socioeconomic status, so they have more access to, you know, the things that they need and cognitive stimulation even as they get older. But that's just a hypothesis. Midlife hypertension contributes to the development of vascular problems, which can lead to stroke and the development of vascular dementia. Hypertension needs to be addressed. Hypertension is largely preventable. There's, you know, physiological factors, cholesterol and all that stuff that can contribute to poor cardiovascular health. But there's also psychological factors, stress management, coping skills, anger, you know, all that stuff. Obesity increases the risk of dementia in general by 42%. It increases the risk of Alzheimer's by 80% and vascular dementia by 73%. Obesity is a big issue, you know, and we've talked before about some of the other things that obesity contributes to. But it is important to make sure that people are managing that because we see that it does have a significant impact on the development of cardiovascular and cognitive issues. Diabetes can contribute to the development of dementia through causing systemic inflammation and through instability of blood sugar, as well as secondary consequences of diabetes like liver and kidney dysfunction that can contribute to cognitive dysfunction. Managing diabetes, really important hearing loss. When people don't hear as well, they get frustrated in conversations and may not engage with others as much when they don't, when they start withdrawing, they don't have that cognitive stimulation of being around others. And they also tend to feel more depressed, hopeless, helpless, isolated, which contributes to systemic inflammation and cognitive problems. Old age, smoking, I thought that was interesting. Is not all smoking, but smoking in old age. So smoking when they're older can contribute to dementia. Depression can contribute to the development of dementia and vice versa. Hypercortisolism, when people are initially. When they have high levels of anxiety, high levels of cortisol create a neurotoxic environment and an inflammatory environment in the brain that's been associated with the development of dementia. And since a lot of people have concurrent anxiety and depression, we want to look for that. Physical inactivity reduces the oxygenation in the blood, reduces circulation. That can contribute to dementia and social isolation. Social isolation and finally, traumatic brain injury from falls. As people get older, they tend to have more difficulty with balance. They have slower reaction times. If they fall, they hit their head. It can cause swelling, concussions, and other issues that can contribute to the development of dementia. So interventions encourage Supervised, you know, medically supervised physical activity, maintenance of their treatment plan to control their blood pressure, not smoking, social engagement, depression prevention and intervention. That's a broad category there, and that will differ for different people. And it's important to. But it's important to explore some of those things. And there are going to be periods of grief and depression potentially around life transitions. For example, when somebody goes into assisted living, when their spouse of 30 years dies, when, you know, fill in the blank. So there are going to be episodes of depression. Technically, according to the dsm, they'd probably be more diagnosable as adjustment disorder because a lot of these episodes of depression are due to an acute stressor. However, they're depressed, they're feeling depressed. That's really what we want to take home from this. And diabetes management. You know, all of these things can be really helpful, as well as making sure the older adult is having their vision and hearing screened on an annual basis to make sure that they are as able to participate in their environment as possible. Chronic health conditions. We can see medication buildup or side effects. A lot of people who are older do not go to a physician who specializes in geriatric medicine. As people get older, their liver clears medication a lot more slowly, their body processes medication a lot differently. So certain medications can become toxic or have more profound side effects. In older adults, pain, unfortunately, tends to happen just as a course of, you know, getting older. You start having a little arthritis here and a cramp here. But chronic pain contributes to HPA axis activation, contributes to inflammation, contributes to poor sleep, and contributes to a reduced quality of life. We want to work with people to advocate with their physician as well as potentially a physical therapist. But also we can work with them on some cognitive strategies, mindfulness and meditation strategies, and guided imagery to address any pain that they're experiencing. Increased injury risk is a big issue. You know, they may fall more often. It may take wounds a little longer to heal, especially for people with diabetes. You know, we have delayed wound healing and sometimes there's peripheral neuropathy. So they may get an injury and not even feel, feel it. So it is important to encourage people to be cognizant of their environment and, and make it as safe as possible. Chronic health conditions reduce physical activity. So we want to work with the person as well as their physician to identify what they can do, and we can work with them to help increase their motivation to engage in some sort of meaningful physical activity, you know, whatever that looks like for that person. And the key is meaningful. You know, it may Be going on a walk, it may be feeding the birds, it may be playing with their dog or their, you know, grandchild, whatever it is. But we need to identify what is meaningful physical activity for this person. Chronic health conditions contribute to sleep impairment. Again, with adults, especially older adults, it's going to be a multidisciplinary team. So referring them for a sleep evaluation is going to be important, and they may go for a sleep study. Getting their apnea, if they have it addressed, is going to be important. But also we can work with them as far as educating them about sleep hygiene. As people age, it's a fallacy that they need less sleep. As people age, they still need seven to nine hours of good quality sleep every night. And if they're not getting it, we need to examine why. Is it because they've got a pee three times a night? Well, what can we do about that? Is it because they're having hot flashes, you know, multiple times a night? Okay, what can we do about that? Social support tends to go away or not be there for a lot of people with chronic health conditions. Could be because their mood, because they're cranky, and they tend to alienate people. So we want to look at that and make sure that they've got some compassionate, supportive people. Or it could be like in the case of my grandmother, they just refuse to ask for help even though they need it, and they tend to be more withdrawn. If people start withdrawing, we want to examine what is that behavior saying? What are they trying to communicate? Maybe they can't hear us and understand what we're saying anymore. Maybe we're talking too fast and they just can't process it that quickly and they get frustrated. Chronic health conditions often are treated with certain medications, so we do want to pay attention to any medication interactions or any other supplements that the person's taking. Frailty syndrome is a geriatric syndrome characterized by the clinical presentation of identifiable physical alterations such as loss of muscle mass and strength, energy and exercise tolerance, and decreased physiological reserve. They get wiped out really quickly. This can be due to malnutrition, lack of exercise, or depression. Horticulture therapy gardening shows great potential in enhancing mental health, cognitive functioning and physical health in the elderly, Especially if you're using raised garden beds, they don't have to stoop down. Or if you're using, you know, potted plants. Just being able to tend to something can give some meaningful activity to people. In terms of medication, age related physiological changes that can impact drug effects include changes in absorption, they're increasing gastric ph and decreasing absorptive surface in their, in their system can affect the level of medication that gets into their blood system. They have a difference in the way their body distributes medication because there's a decrease in total body water, lean body mass and serum albumin. They have decreased hepatic liver mass and blood flow. So the metabolism of their medication that is often metabolized by cytochrome P450 in the liver tends to go down, tends to slow down, and excretion changes generally slows because of decreasing renal or kidney blood flow, glomerular filtration rate and tubular secretion. So your body has a hard time, you know, pushing out the bad stuff. Some of the most common medicines likely to have adverse effects include anticoagulants, antibiotics, who knew? Diuretics like Lasix, hypoglycemic agents, benzodiazepines. This is a big one. Opioids and NSAIDs, your ibuprofen and naproxen type medications. Hormonal changes and other physiological changes associated with aging affect sexual interest. Erectile dysfunction is a problem in men, increasing with age, diabetes, cardiovascular cancer and chronic respiratory diseases. And also some medications may also reduce sexual capacity and desire. The most common cause for male erectile dysfunction are vascular diseases, which, you know, cardiovascular diseases. Age is not a barrier to sexually transmitted diseases. And in women, lack of emotional well being and a sense of intimacy during sexual intercourse can lead to reduced sexual interest. It's important to recognize that even older people, you know, sexual desire, our need to connect our, you know, benefits of oxytocin don't go away with age. So it is important to support healthy sexuality in older adults. Healthy sexuality prompts bonding and it helps them feel more whole. When they don't have that aspect, they may feel like they part of their life is missing and they may be grieving that the causes of malnutrition can stem from other health problems. Bariatric surgery, dementia that causes people to forget to eat, depression, which people just may not want to eat or they eat poorly. You know, not all nutrition is created equal, so we want to. It's not just the calories, but the quality of the nutrition. Alcoholism contributes to malnutrition because it prevents the absorption of certain vitamins and minerals. Dietary restrictions, reduced social contact, limited income, reduced mobility and dental problems all also contribute to malnutrition. So if you're working with an older adult, making sure that, you know, their dentures, if they have them are fitting right so they can eat effectively, that they are able to get into their kitchen and access everything they need so they can cook what they want to cook or they know how to order in. Encourage them to engage with other people. Reduced social contact can contribute to depression, but when you have reduced social contact, you also don't have somebody noticing, hey, doesn't seem like you've eaten anything in a week or so. Sleep needs don't decrease with age. Short and long sleep duration groups had increased prevalence of mental health issues by 66 and 26%. So people who slept less than seven hours had a 66% increase in mental health issues and people who slept more than than nine hours had a 26% increase in mental health issues. Poor quality, insufficient sleep is associated with poorer physical function and cardiovascular issues with aging. Slow wave sleep that deep sleep that we need to get rejuvenated to clear out the adenosine from our brain. Less slow, slow wave sleep is expected along with more awakenings and a tendency towards earlier sleep times. Our circadian and rhythms actually move a little bit as we age, but there are a lot of ways that we can prevent some of the frequent awakenings like slowing down the fluid intake after a certain hour. Causes of sleep problems Bladder control issues. Now obviously not drinking 36 ounces of fluid right before bed, that's going to help for some people. They may need to wear adult undergarments when they're sleeping so it doesn't wake them up. Or if they have don't have bladder control for men, they may need to have their prostate evaluated. So there are a lot of things that a urologist can help. People with neurological conditions, lung diseases including asthma and copd, chronic pain, sleep apnea, anemia, interestingly enough, and gastroesophageal reflux disease or really bad heartburn can all cause sleep problems. All of these do have interventions that the physician can use to help people may not solve it completely, but there are a lot of interventions that can make life a lot better. Rapid eye movement Sleep behavior disorder often represents the earliest sign of Lewy Body Dementia. In rem sbd, people often act out vivid, unpleasant dreams with vocal sounds and sudden, often violent arm and leg movements during REM sleep. So if somebody starts, you know, they've generally slept pretty calmly most of their life and suddenly they start having these violent arm and leg movements during their REM sleep. It's worth getting looked at and a lot of times the person will be referred for a sleep study because it is such a good indicator of Lewy Body dementia. And there are some medications that can Help slow that progression. Social support serves major functions including emotional support, duh, informational support. People who can provide advice and guidance, like case managers and congregational care managers and pastors and, you know, health educators and then instrumental support are people either within the person's social circle or in the community that can provide rides or assist with housekeeping and those sorts of things. And my mother's church, they used to have a list of volunteers who were willing to come in and help out during tough times for people in the congregation, either, you know, after a surgery or something, help with cooking meals or housekeeping or mowing the lawn or doing things like that that, you know, not forever, but as a temporary stop gap while people were recovering from some sort of life altering or life transitioning event. Adequate social support is associated with reduced risk of mental illness, physical illness and mortality. Older people also often experience retirement blues. You don't really think of it when you're working. A lot of times you're like, oh, I can't wait till retire. It'll be so nice to be able to, you know, sit back and relax. But a lot of us have our social needs met and our social circle kind of revolves a lot around work. So once you leave work, those people you used to see every day, those routines you used to have, they're gone. And a lot of people don't plan for that transition ahead of time and have, you know, another set of activities to go into so people can start feeling very withdrawn and very unsteady after they retire. And yes, you're identity of self changes when, when you're retired because you see yourself, you know, that's another marker towards becoming older and it's a role you no longer embrace. Just like when children move out and people develop empty nest syndrome because it's I'm no longer 24 hour mom. Well, that's when a role gets put kind of on the back burner because you're not doing it or not doing it the same way anymore. It's even more so when you retire because at least when kids move out, you're still mom or you're still dad, but when you retire, you are now, you know, not that thing anymore. We see a lot of retirement issues in soldiers and law enforcement. A lot of people in those two occupations really have difficulty transitioning. Technology based interventions to reduce social isolation have a moderate but short term impact on reducing isolation. You know, facetime, zoom, whatever you can do. And we've had to adjust to a lot of this over 2020 because we couldn't be in person with people. So it's been embraced a little bit more, but it's not the same. You know, watching your grandkids play in the playroom through a zoom camera is not the same as sitting on the floor and playing with them. But you know, it is a stop gap to a certain extent. And people do benefit from telephone or video based contact. Especially older adults who live alone benefit from that on a regular basis. Social support intervention should focus on connecting the person to the outside world, helping them gain social support, helping them engage in meaningful activities and boosting self confidence. Life satisfaction is the self evaluation of one's life as a whole and is influenced by their socioeconomic, health and environmental factors. Life dissatisfaction is associated with obesity and risky health behaviors such as smoking, physical inactivity and heavy drinking which all impact the risk of dementia. Life dissatisfaction is often associated with depression. Depression is associated with inflammation and dementia as well as less healthy lifestyle behaviors. Cultural differences impacting treatment different cultures may have different conceptualizations of issues like independent living. You know, not all cultures. Some cultures embrace multi generational households, other cultures not so much. So moving mom or grandmom in may be be received differently in different cultures. They may have different ideas of appropriate interventions, whether it is spiritual, medicinal, environmental, you know, there are a lot of different avenues. So it's important to ask the person what is your perception of the problem? What do you think's causing it? What do you think might help improve it? You know, get it from them because they probably have some ideas. There may be a suspiciousness of strangers or white coat syndrome and, and submit suspiciousness of strangers. You know, you got to keep yourself safe. When people are older, they often feel more vulnerable and unfortunately for good reason. So it's important to make sure they're safe. White coat syndrome is generally when somebody will not speak up to a doctor, they will not advocate for themselves. And I've seen, I saw it, used to see it a lot with my grandma. You know, as soon as she'd walk in there, whatever the doctor said was just fine. And if the doctor didn't ask her any questions, she didn't offer any information. They may have different expressions of distress. You know, some people will get moody, some people will get withdrawn, some people will be very open about their distress. Some people will ask for help and other people will not. They see it as shameful, especially for mental health issues. To identify distress, they may feel like, like it brings shame on their family. And people may have limited resources, they may not be able to afford assisted Living or, you know, full time in home care Treatment principles. Therapeutic interventions to encourage autonomy and empowerment include case management. And I really encourage you, if you work with older adults or you have one in your family, review that needs assessment. You can fast forward through it and just read the slides if you want, but review that needs assessment video that I did on, that's on the YouTube channel because there are a lot of things that I wouldn't have thought about to check on daily living skills. You know, we want to help the person stay as independent as possible for as long as possible. So what do we need to help them with? Improving safety at home and provision of practical support and information, including their social and legal rights. What are your rights in these situations? What are your rights in with your insurance company, with long term care insurance? What are your rights, you know, if, if you live in a 55 plus community, you know, helping make sure that they know what their social outlets are as well as their legal rights. Older people with mental illnesses, particularly depression or dementia, may take longer to respond to treatment. Interactions between medication and comorbid physical illnesses and their treatment are also common. Sometimes it can be good. You know, treatment of one condition can improve another. You know, treatment of hypertension often helps improve depression, you know, interestingly enough, but it can also go the other way. If somebody starts taking opioids, for example, it may contribute to them developing depression, more depression. So we do want to be sensitive. It's important to address coexistent physical and mental health issues because they interact. Social engagement, physical activity, control of diabetes and hypertension, prevention of depression and developing a sense of life satisfaction are all associated with positive health outcomes and a reduced risk of depression and dementia. Obviously with older adults there is a whole lot more, but I couldn't fit it into an hour. But there is a whole lot more to cover and to consider in order to help them feel empowered to embrace their highest quality of life. And that's really what we want to do, is help them stay as independent as possible and have a rich and meaningful life as they define it, for as long as possible.