Despite the obvious need for inpatient healthcare models that meet the needs of adults as we age, current healthcare models are limited in their ability to provide sensitive, patient-centered care to older adults. Current models of healthcare administration in inpatient hospital settings are typically individualistic in nature and focus on the dyadic relationship between the patient and the provider. Additionally, fragmented care in which each medical condition is addressed by a specialist can reduce responsiveness to multiple comorbid conditions common among older adults. Finally, older adults can experience ageism and stigmatization when admitted in the hospital.
Alternative healthcare models can increase sensitivity to the needs of older adults through integrated healthcare models, inclusion of mental health clinicians in hospital settings, and acknowledging and actively resisting ageism and bias when working with older adult patients (American Psychological Association, 2008; American Psychological Association, 2014; Liljas et al., 2019).
Recommendations for practice with older adults admitted to the hospital include use of patient and family-centered care using an integrated team model, and ensuring the care encompasses the older adult’s preferences, health literacy, and values.
Psychological Assessment of Older Adults in Inpatient Hospital Settings
Ethical Practice with Older Adults
The American Psychological Association (2014) encourages psychologists working with older adults to ensure they practice within their scope of competency, and when necessary, seek education and supervision to work with older adults as necessary. One potential resource is the Foundational Competencies in Older Adult Mental Health Online Certificate Program.
When assessing older adults, mental health clinicians should ensure their assessments are adjusted as needed to make accommodations for sensory-motor or cognitive impairments, including hearing and vision deficits. Clinicians should also be aware that older adults may present differently than younger adults with respect to physical, cognitive, emotional and social functioning. As with all evaluations, clinicians should rely on open-ended questions, behavioral observations and empirically validated tools and collateral information as needed.
The results of evaluations should be communicated to the primary medical team responsible for the older adult’s hospitalization, as well as to other medical team members, including nurses, physical therapists, occupational therapists, speech therapists, respiratory therapists, vocational counselors, and others, as appropriate. The mental health clinician is responsible for collaborating and encouraging coordinated care.
Finally, mental health clinicians should ensure their evaluation is grounded in an understanding of social and cultural factors that have impacted the older adult’s health and life experience.
Domains of Assessment
It is recommended that clinicians assess the following key domains whenever evaluating an older adult in the hospital setting (American Psychological Association, 2014):
- Reason for admission and primary referral question, if using a referral-based service
- Current mental status: motor function, arousal and orientation, eye contact, mood, affect, thought process, thought content, speech
- The patient’s biggest current concern: “What’s most important to you during this admission?”
- The patient’s current understanding of their reason for admission, etiology and deficits.
- Use of clinical interview and/or a validated screener may be indicated, such as the Orientation Log (Jackson & Novack, 1994)
- Pain: intensity, location, quality, triggers and relievers, pain plan satisfaction
- Sleep: pattern at home vs. pattern in the hospital, hours per night, trouble falling and/or staying asleep, nightmares, sundowning or cognitive/orientation changes at night, use of medications
- Appetite and understanding of diet: is the diet the same in the hospital as their diet at home?
- Mood: cardinal signs and symptoms of mental health concerns. Clinicians can consider use of validated screening tools including but not limited to the PHQ-2, PHQ-4 or PHQ-9, GAD-7, PCL-5, and others. Consider older-adult specific measures like the Geriatric Depression Scale (Yesavage et al., 1983).
- Suicidal ideation (SI) with evaluation of intent, plan, and history
- Current signs and symptoms of ASD or PTSD: feeling numb, nightmares, negative emotion, avoidance
- Current strengths and current level of challenge: Clinicians may ask “Is this the hardest thing you’ve been through?” Consider asking “How did you cope with past challenges?”
- Faith: spirituality and preferences for involvement of chaplain or pastoral care. Consider needs for religious services or rites.
- Mental health history prior to admission: outpatient/inpatient treatment, medications, previous diagnoses, history of psychological testing, severe psychiatric symptoms, historic risk assessment including self-harm or SI.
- Substance use: tobacco, alcohol, marijuana/THC products, illicit substances. Clinicians should consider using validated substance use assessment tools including the AUDIT-C, DAST or others. Note that, due to changing physiology with age, current DSM diagnostic criteria may not capture disordered substance use.
- Other relevant medical history including history of brain injury, neurological process, or prior hospitalizations
- Social environment: with whom the patient lives, where they are from, family support and dynamics, marital history, children, etc.
- Educational history: history of grade retention, learning disorder or academic difficulties, years of school completed
- Employment history including current and past work, future goals for employment, service history and deployments or active duty experience, and unpaid work like volunteer work or caregiving responsibilities
- Avocational interests and values
- Patient goals for the current admission
- “What’s Next:” after discharge what psychosocial or medical needs will need to be managed in order to ensure the outpatient plan is congruent with the patient’s goals and values for the admission.
- Cognition/Delirium: Clinicians should use a validated screener depending on the patient’s presentation and be alert for signs or symptoms of hyperactive or hypoactive delirium. Clinicians can consider using tools like the Orientation Log, Cognitive Log, MOCA, MOCA-Blind, or the 3MS. When selecting measures, clinicians should consider instruments with norms available for older adults, such as the Mayo’s Older Americans Normative Studies (MOANS) norms.
Interventions with admitted older adults in hospital settings must be grounded in a framework that acknowledges the potential for ageism and stigmatization. For instance, healthcare providers must be aware of unhelpful and potentially iatrogenic communication patterns when working with older adults, including “Elderspeak.” Elderspeak is a communication pattern between younger and older adults characterized by “baby talk” or slower rate of speech, exaggerated intonation, elevated pitch/volume, simpler vocabulary and grammar (Williams et al., 2004). Healthcare providers may wish to convey care to patients when using Elderspeak, but in actuality, communicate a conscious or unconscious bias that older adults are incompetent or child-like. All providers, including physicians, psychologists, nurses, technical assistants, transport technicians and administrators can benefit from awareness of, and education on alternative to, Elderspeak. Elderspeak is typically characterized by communication styles that including use of:
- Pet names or diminutives (Sweetie, Honey, Grandma, etc.)
- Inappropriate use of the plural “we”
- Insinuations that the older adults’ preferences are incorrect (“Wouldn’t you rather…”)
- Use of slowed rate of speech, increased volume or baby-talk
By using communication strategies that emphasize patient autonomy, competence and collaborative patient-provider relationship, hospital staff can minimize potential for ageism and stigmatization during admissions for older adults.
Delirium and Cognition Treatments
Assessing for and treating delirium is crucial in the care of hospitalized older adults. Delirium is an acute condition marked by a disturbance in orientation, cognition (specifically attention), and perception. Risk factors for delirium include older age, baseline cognitive impairment, use of deliriogenic medications such as benzodiazepines, functional impairment, sensory impairment, and impaired sleep (Holroyd-Leduc, Khandwala, & Sink, 2010). It is important for clinicians to identify and treat delirium as early as possible during a patient’s medical course as it is associated with poorer health outcomes such as increased medical complications and length of hospitalization (Marcantonio, 2017).
Delirium can be assessed through the use of tools such as the Confusion Assessment Method (CAM) tool and its short form such as the 4AT and UB2, or the Orientation Log (O-Log) (Jackson, Novack, & Dowler, 1998; Wei, Fearing, Sternberg, & Inouye, 2008). While both tools assess mental status, the CAM includes structured behavioral observations by clinicians.
A coordinated team approach is essential to both prevent and treat delirium and can include the following (Aguirre, 2010; Holroyd-Leduc, Khandwala, & Sink, 2010; Marcantonio, 2017):
- Frequently orienting patients to self, time, place, and situation. Room clocks must be correct, and the month, date, and year should be correctly written on a whiteboard that is visible to patients
- Ensure patients have access to glasses and hearing aids
- As medically appropriate, allow mobilization through engaging patients with PT and OT, especially early on in their hospitalization
- Regulate sleep/wake cycles by encouraging patients to stay active during the day, minimize daytime napping, and to keep shades open and lights on during daytime hours. During sleep hours, shades should be drawn, lights should be turned off, and environmental noises should be minimized through keeping room doors closed as appropriate. Some patients may also benefit from ear plugs or eye masks for sleeping. As medically appropriate, minimize any sleep interruptions for medications or assessments.
- As available, it is helpful to have patients’ support systems bring in items that are familiar to patients (e.g., photos, cards, encouraging signs, favorite clothing items) to reduce anxiety and assist with orientation.
- Cease use of deliriogenic medications as medically appropriate
- Treat medical contributors to delirium such as dehydration and malnutrition
Initial Treatment of Mood and Referral Post-Discharge
As part of the initial evaluation, clinicians should assess for mood and coping concerns (see Domains of Assessment) through the use of open-ended questions and subjective mood measures. Treatment options include psychotherapy and pharmacological treatment.
Across all ages, depression and anxiety are effectively treated through evidenced-based psychotherapy including Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and Interpersonal Psychotherapy. For older adults, themes explored in therapy may involve adjustment to functional decline and complex medical conditions, grief, and end of life issues (American Psychological Association, 2014).
It is possible to begin talk therapy in the hospital, however, this setting presents a number of unique challenges. One of these challenges is the dynamic nature of the hospital where patients are engaging with multiple teams and providers. Patients may not always be available for psychotherapy treatment, which may make regular therapy sessions difficult. Their length of stay may also be unknown due to the complexity of the medical condition being treated. Thus, it is important for mental health clinicians to clarify their role on the team and to discuss realistic expectations for treatment with teams. These expectations should also be communicated to patients and mental health clinicians should collaborate with patients on treatment goals. In developing goals, clinicians should always ask patients what is most important to them during the admission process so that goals reflect patients’ priorities.
Another challenge is a patient’s willingness to start therapy while admitted. Patients may understandably not be ready to address psychological concerns during hospitalization and may also want to prioritize medical goals. Mental health clinicians can instead focus treatment on building rapport with patients and providing extensive education regarding coping and mood, mental health treatment options, and other health and behavior concerns (e.g., nonpharmacologic pain management, education on sleep hygiene, etc.). As appropriate, clinicians may include patients’ support persons in treatment and education sessions.
If use of psychotropic medications is indicated, consultation from geriatric psychiatry is warranted. This subspecialty of psychiatry is recommended given the older adults’ high risk for complications due to polypharmacy. If this service is not available, clinicians should collaborate with pharmacists and reference the Beers Criteria For Potentially Inappropriate Medication Use in Older Adults to minimize the drug interactions and side effects. Continuity of care in an outpatient setting is highly encouraged and outpatient psychiatric referrals should be provided upon discharge (American Psychological Association, 2014).
Written by Abigail Harding, PhD and Christina Khou, PhD, Rush University Medical Center
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