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Mental health issues of older adults

Spring 2013 • Vol. 37 .No. 1 | 27

G E N E R AT IO N S – Journal of the American Society on Aging

Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail: info@asaging.org. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.

Mental health care for older adults lags behind that for other age groups, in both
the developed and developing world. Helping
older adults and healthcare providers identify
potential mental health problems is an impor-
tant first step toward ensuring better care. In
the coming decade, we must turn clinical and
research attention to cohorts such as the oldest-
old and those of culturally and linguistically
diverse backgrounds. Varying national and
cultural systems are reflected in how nations
organize and deliver healthcare services,
including mental health care, but all
are under increasing pressure because
of the growing numbers of frail older
adults and of those with dementia. The
need also is accelerating for age-literate
mental health care workers. In many regions of
the world, there are policy issues and directives
that pertain to older populations’ mental health,
while in many other areas such initiatives are
still evolving.

This article describes issues confronting older
people—as well as the healthcare systems that
serve them—in developed and developing nations.
It highlights recent research and reviews to point

out critical issues affecting older adults globally,
and presents challenges and future directions for
research and clinical practice.

Identifying Mental Health Problems
in Older Populations
The aging of the population has focused atten-
tion on the mental health of older adults, from
the perspectives of clinical practice, research
inquiry, service delivery, and government policy.
But first, how can we identify those in the com-

munity in need of mental health services?
Traditionally, mental health diagnostic

systems have not been particularly concerned
with how symptoms present in later life. This
has changed recently with revisions, both
suggested and anticipated, to the Diagnostic and
Statistical Manual of Mental Disorders (DSM),
as well as to the World Health Organization’s
International Classification of Diseases. Recent

By Nancy A. Pachana

A Global Snapshot of
Mental Health Issues,
Services, and Policy

Changing global demographics have prompted
new thinking about policy concerning mental
health priorities in later life.

‘Traditionally, diagnostic systems have not
been particularly concerned with how mental
health symptoms present in later life.’

G E N E R AT IO N S – Journal of the American Society on Aging Pages 27–32

28 | Spring 2013 • Vol. 37 .No. 1

discussions around proposed DSM5 (fifth
edition) changes have highlighted issues with
respect to diagnosing older adults of culturally
diverse backgrounds. One goal of the DSM’s
current revision is to ensure culturally appro-
priate approaches to those with mental health
issues (American Psychiatric Association, 2011),
which is crucial given increasing global migra-
tion within all age groups.

Cultural diversity raises particular issues for
older adults. Rose and Cheung (2012) have done
a qualitative analysis of published studies on
assessing mental health in such populations
with respect to proposed DSM5 changes. They
highlighted five issues: degrees and processes of
acculturation; unique cultural experiences with
respect to mental health issues; health dispari-
ties among various cultural groups within a
given society; evidence-based dementia practice;
and, diverse prevalence of anxiety and depres-
sion across cultural groups. As DSM criteria are
used in a variety of settings, the authors con-
clude that competence in assessing mental
health problems across diverse populations is
growing in importance and deserves careful
consideration in the diagnostic process.

Part of the difficulty in assessing mental
health concerns between both diverse cultural
groups and within the majority culture, is the
idea that mental health problems are to be
expected later in life. Anxiety and depression
prevalence rates have been published in numer-
ous countries for diverse groups, and yet a stereo-
type of depression and anxiety being “normal” in
later life remains. For example, the U.S. Centers
for Disease Control (2008) noted that contrary
to popular belief, older adults older than age 65
do not report experiencing frequent mental

distress, and lifetime histories of depression and
anxiety are low (10.5 percent and 7.6 percent,
respectively). These percentages are lower than
those reported for adults ages 50 to 64 years (19.3
percent and 12.7 percent, respectively).

Despite research on older adults’ interper-
sonal and psychosocial resources, this ageist
myth persists among both healthcare profession-
als and older adults (Whitbourne, 2001). More

recently, Bryant and colleagues (2012)
examined attitudes among older adults
toward aging and the impact of such
attitudes on quality of life. Adults older
than age 60 (N=421) were asked to
complete questionnaires rating their
attitudes toward aging and various

quality-of-life issues and self-reporting mental
health problems. More positive attitudes toward
aging in this group were associated with a higher
level of satisfaction with life, better self-reported
physical and mental health, and lower levels
of self-reported anxiety and depression. This
shows ageist attitudes are of concern, not only
in identifying mental health problems, but also
as an important risk factor in their development
in later life.

Subgroups of Particular Interest
Approximately 36 million people worldwide live
with dementia, and these numbers are set to
double every twenty years to approximately 115
million by 2050 (Alzheimer’s Disease Interna-
tional, 2011). Most dementia care is provided for
patients in their homes, and providing such care
takes a toll in terms of health, social, economic,
and emotional costs (World Health Organization
[WHO], 2012). In its 2012 report on dementia,
the WHO strongly urges nations to structure
dementia care policies that balance searching for
a cure with providing quality evidence-based
care for those currently affected.

In light of this directive, the recent meta-
analysis of high-quality dementia caregiver
interventions by Brodaty and Arasaratnam
(2012) offers good news. In this analysis,

Many psychotherapists working with older
people may be confronted with their own
unacknowledged fears about increased
disability, aging, and mortality.

Our World Growing Older: A Look at Global AgingPages 27–32

Spring 2013 • Vol. 37 .No. 1 | 29

twenty-three such studies were examined,
involving 3,279 family caregivers of community-
dwelling persons with dementia. There were
demonstrated reductions in behavioral symp-
toms and negative caregiver reactions from the
interventions. These improvements, although
modest, compare favorably to trials using
drug-based treatments. The most successful
interventions were tailored to specific behav-
iors, needs, and contexts of the care situation.
Improvements in both behaviors and caregiver
well-being can help those with dementia live
at home longer, with few or no adverse side
effects, compared to drug treatments. In light
of recent published concerns about the use of
anti-psychotics in older persons with dementia
(Steinberg and Lyketsos, 2012), this study pro-
vides powerful evidence that such psychosocial
interventions should be central to managing
behavioral symptoms in dementia.

Another subgroup of the global aging pop-
ulation receiving increased attention is that of
the oldest-old (ages 85 years and older). Globally,
the fastest growth in population is seen in this
age group, with projections for a nearly fivefold
increase in this group by 2050, from 88 million
in 2005 to 402 million (United Nations Depart-
ment of Economic and Social Affairs [UN DESA],
2007). Importantly, 80 percent of older people
will live in low- and middle-income countries,
with an increasing proportion of these also
comprising frailer older adults of more advanced
ages (UN DESA, 2010). Although we may make
distinctions and assumptions about adults who
fall into young–old and old–old categories, older
adults are a heterogeneous group and likely to
become even more so as longevity increases.
This is an important point to carry into clinical
work with older adults: while chronological age
may provide some limited orienting information
about general expectations, at an individual
level, the older person’s unique context and
perspective are all-important, making age
perhaps the least important clinical variable
(Laidlaw and Pachana, 2009).

Perhaps most important is that healthcare
providers have a good working knowledge about
normal aging from young−old to old−old popula-
tions, despite research still tending to focus on
relatively younger cohorts in the latter half of
life (Laidlaw and Pachana, 2009). Older adults
express preferences for various treatments for
mental health concerns at different ages, be they
pharmacological or non-pharmacological, and
their voices need to be heard. Mohlman (2011)
found in a survey of community-dwelling
participants (N=383) a self-reported preference
among young–old adults (ages 65 to 74) for
cognitive-behavioral therapy for anxiety-related
disorders, while the oldest–old group was more
likely to prefer supportive therapy. Finally, with
increasing proportions of older adults of ad-
vanced age seeking treatment, many psychother-
apists working with older people may be con-
fronted with their own unacknowledged fears
about increased disability, aging, and mortality.
What may have been an abstract concept of
morbidity and frailty may now become discom-
fortingly real (Koder and Helmes, 2008).

Training and Workforce Issues
This notion of mental health workers across
disciplines needing to confront ideas of ageism,
bias, discomfort, and anxiety points to the need
for more training in working with older adults.
Such calls for additional training have spanned
disciplines (e.g., psychiatry; Jeste et al., 1999)
and regions of the world (for example, Portugal
responded to its aging population with innovative
multi-disciplinary healthcare training initiatives;
Ribeiro et al., 2010). Improving training in mental
health care for older adults requires attracting
students into this sub-discipline, ensuring curri-
cula match the needs of older adults, and pro-
viding high-quality placement experiences for
students, with adequate supervision.

Unfortunately, such training lags. A study by
Pachana and colleagues (2010) compared issues
of staffing, pedagogical content, and placement
opportunities across clinical psychology training

G E N E R AT IO N S – Journal of the American Society on Aging Pages 27–32

30 | Spring 2013 • Vol. 37 .No. 1

programs in the United States, Canada, and
Australia. Across countries the more salient
findings included the intertwined issues of a
need for academic staff with geriatric expertise
and training programs focusing on diagnosis
and assessment, with relatively little attention
paid to interventions. Such studies offer a way
to argue for curriculum and staffing changes
within clinical training programs.

The WHO (Global Agenda Council on Aging
Society [GACAS], 2012) has highlighted the
broader issue of adequately preparing healthcare
providers to serve the needs of an aging popula-
tion. The report stressed a need for medical
school students to gain greater exposure
to geriatric medicine, particularly in the
care of those older than age 85 who have
complex medical problems. Curricula
must note the need for more geriatric-
literate healthcare workers. Recently,
the Association of Geriatrics and Gerontology
and the WHO have put forth core competencies
that should be addressed in medical training,
irrespective of final specialization area (Mateos-
Nozal and Beard, 2008). Meeting such compe-
tency objectives in training will help assure
quality patient outcomes in the future.

The Organization of Healthcare Services
The way in which healthcare services are orga-
nized reflects a country’s history of providing
health services, funding schemes, cultural
priorities, and economic realities. These differ in
the developed and developing world, although in
all countries increasing proportions of geriatric
patients are causing strain in healthcare delivery
systems, albeit to varying degrees. Globally,
mental health care systems are tied to these same
drivers and are also particularly sensitive to cul-
tural norms and economic development levels.

Healthcare organization and policy will
differ between countries with varying degrees
of development and economic resources. Chal-
lenges and opportunities differ here. Health-
care systems and priorities in wealthier, more

developed countries were formed in an era
where acute illnesses and younger patients were
the focus of their societies. Now these systems
must retool (and their managers must rethink)
healthcare service delivery in light of changing
demographics and priorities. Prevention,
including primary, secondary, and tertiary
prevention of diseases or conditions common
in later life, must become prominent (GACAS,
2012). New models of cost-effective and innova-
tive care systems should be tried, such as the
geriatric-specific emergency room care in
increasingly widespread use in the United
States (Hwang and Morrison, 2007).

In less developed and more economically
challenged regions of the world, a serious prob-
lem is that aging populations will present with
more costly non-communicable diseases, seeking
treatment at healthcare centers often lacking in
infrastructure and geriatric specialists (GACAS,
2012). In the developing world, healthcare com-
petes with other priorities (education, food,
and security). And rapid development has altered
traditional family- and community-based care
systems for older adults in these societies. A more
proactive stance is required; suggested priorities
would include emphasizing prevention and non-
communicable diseases; encouraging healthcare
workers to move to rural areas and supporting
training for these workers; adapting technology to
suit local realities; targeting the poor and under-
served; and developing a primary healthcare
sector (GACAS, 2012).

The WHO (2011) has developed and evalu-
ated a toolkit based on age-friendly primary
healthcare centers, offering a model for both
developed and developing countries to orient
them more toward meeting the needs of older
adults. (The toolkit is freely available and can be

One international trend is to consider using
interdisciplinary care systems for both
health and mental health care services.

Our World Growing Older: A Look at Global AgingPages 27–32

Spring 2013 • Vol. 37 .No. 1 | 31

downloaded at www.who.int/ageing/publica
tions/upcoming_publications/en/index.html.)

Policy Issues and Initiatives:
A Global Snapshot
Across the globe, changing demographics have
prompted rethinking policy with respect to
mental health priorities in later life. One major
trend is thinking more seriously about having
inter-disciplinary care systems in place for
providing both health and mental health care
services. Such systems have good empirical
support with respect to efficacy and outcomes
efficiency (Heinemann and Zeiss, 2002). Basi-
cally, in less hierarchically organized systems,
care for older adults, particularly those with
multiple comorbidities, can be less fragmented,
and can be more sensitive to varying life experi-
ences and contexts. The American Psycholo-
gical Association (2008) offered a blueprint for
achieving integrative healthcare solutions for
older populations. An integrated healthcare
model is characterized by a high degree of
collaboration between various health profession-
als serving patients at all stages of care, including
assessment, treatment planning and implemen-
tation, and evaluation of outcomes. It is more
collaborative than hierarchical in its organiza-
tion and has a strong capacity to flexibly meet
challenges of diverse presentations and circum-
stances. This model is appropriate across a
variety of settings (primary care, residential
care) and could be adopted in both developed
and developing nations as an aspirational model
for excellence in geriatric care.

In Australia, where models and policies
regarding health and mental health care for

older adults across settings have been develop-
ing over the last decade, a new initiative is worth
noting. The Australian government recently
announced the development of a Lesbian Gay
Bisexual Transgender Intersex (LGBTI) Ageing
and Aged Care Strategy to ensure the needs of
these groups are met. Historically, LGBTI
persons have faced stigma and discrimination in
accessing and using aged care services. Various
recommendations of the Australian National
LGBT Health Alliance (2010) included funding
national training for aged care workers on
LGBTI issues for older adults, and an LGBTI
aging strategic plan to ensure the aging services
sector could be sensitive to and supportive of
older LGBTI people’s needs.

Conclusion
Global population aging has brought with it
significant challenges and increased research
into the mental health care needs of older adults.
We are starting to see innovative solutions in
ascertaining needs, developing and implement-
ing interventions, and supporting an age-literate
mental health care workforce. Research support-
ing efficacious and efficient organization of
mental health care services is increasingly
informing policy initiatives in both the devel-
oped and developing world. Ensuring that
marginalized and under-studied populations
are included in these efforts is a key challenge
in the coming decade.

Nancy A. Pachana, a clinical psychologist and neuro-
psychologist, is a professor in the School of Psychology
at University of Queensland, Australia, and is co-direc-
tor of the University’s Ageing Mind Initiative.

References
Alzheimer’s Disease International.
2011. World Alzheimer Report: The
Benefits of Early Diagnosis and
Intervention. alz.co.uk/research/
world-report-2011. Retrieved
September 20, 2012.

American Psychiatric Association.
2011. DSM-5: The Future of
Psychiatric Diagnosis. dsm5.org/
Pages/Default.aspx. Retrieved
September 20, 2012.

American Psychological Asso-
ciation. 2008. Blueprint for
Change: Achieving Integrated
Health Care for an Aging Pop-
ulation. Washington, DC.

G E N E R AT IO N S – Journal of the American Society on Aging Pages 27–32

32 | Spring 2013 • Vol. 37 .No. 1

Brodaty, H., and Arasaratnam, C.
2012. “Meta-analysis of Nonphar-
macological Interventions for
Neuropsychiatric Symptoms of
Dementia.” American Journal of
Psychiatry 169: 946–53.

Bryant, C., et al. 2012. “The
Relationship Between Attitudes to
Aging and Physical and Mental
Health in Older Adults.” Interna-
tional Psychogeriatrics 24(10):
1674–83.

Global Agenda Council on Ageing
Society (GACAS). 2012. Global
Population Ageing: Peril or
Promise? Geneva, Switzerland:
World Economic Forum.

Heinemann, G. D., and Zeiss, A. M.,
eds. 2002. Team Performance in
Health Care: Assessment and
Development (pp. 3–17). New York:
Kluwer Academic/Plenum
Publishers.

Hwang, U., and Morrison, R. S.
2007. “The Geriatric Emergency
Department.” Journal of the
American Geriatrics Society
55(11): 1873–6.

Jeste, D. V., et al. 1999. “Consensus
Statement on the Upcoming Crisis
in Geriatric Mental Health:
Research Agenda for the Next 2
Decades.” Archives of General
Psychiatry 56(9): 848–53.

Koder, D. A., and Helmes, E. 2008.
“Predictors of Working with Older
Adults in an Australian Psycho-
logist Sample: Revisiting the
Influence of Contact.” Professional
Psychology: Research and Practice
39: 276–82.

Steinberg, M., and Lyketsos, C. G.
2012. “Atypical Antipsychotic
Use in Patients with Dementia:
Managing Safety Concerns.”
American Journal of Psychiatry
169: 900–6.

United Nations Department of
Economic and Social Affairs (UN
DESA). 2007. World Population
Prospects: The 2006 Revision,
Highlights (Working Paper No.
ESA/P/WP/WP.202). Geneva,
Switzerland: United Nations
Population Division.

UN DESA. 2010. World Population
Prospects: The 2008 Revision
Population Database. Geneva,
Switzerland: United Nations
Population Division.

U.S. Centers for Disease Control
and Prevention and the National
Association of Chronic Disease
Directors. 2008. The State of
Mental Health and Aging in
America. Issue Brief 1: What Do
the Data Tell Us? Atlanta, GA:
National Association of Chronic
Disease Directors.

Whitbourne, S. K. 2001. Adult
Development and Aging: Biopsycho-
social Perspectives. New York: John
Wiley & Sons.

World Health Organization (WHO).
2011. Age-friendly Primary Health
Care (PHC) Centres Toolkit.
Geneva, Switzerland: WHO.

WHO. 2012. Dementia: A Public
Health Priority. Geneva, Switzer-
land: WHO.

Laidlaw, K., and Pachana, N. A.
2009. “Aging, Mental Health, and
Demographic Change.” Profes-
sional Psychology: Research and
Practice 40(6): 601–8.

Mateos-Nozal, J., and Beard, J.
2008. “Global Approaches to
Geriatrics in Medical Education.”
European Geriatric Medicine
2(2): 87–92.

Mohlman, J. 2011. “A Community
Based Survey of Older Adults’
Preferences for Treatment of
Anxiety.” Psychology and Aging
(e-pub ahead of print). DOI
10.1037/a0023126.

National LGBT Health Alliance.
2010. “Submission to the Produc-
tivity Commission Inquiry into the
Aged Care System in Australia,
‘Caring for Older Australians.’ ”
pc.gov.au/__data/assets/pdf_
file/0020/100937/sub138 .
Retrieved September 21, 2012.

Pachana, N. A., et al. 2010. “Gero-
psychology Content in Clinical
Training Programs: A Comparison
of Australian, Canadian and U.S.
Data.” International Psychogeriat-
rics 22(6): 909–18.

Ribeiro, O., et al. 2010. “Geropsy-
chology and Psychogeriatrics in
Portugal: Research, Education and
Clinical Training.” International
Psychogeriatrics 22(6): 845–63.

Rose, A. L., and Cheung, M. 2012.
“DSM-5 Research: Assessing the
Mental Health Needs of Older
Adults from Diverse Ethnic
Backgrounds.” Ethnic and Cul-
tural Diversity in Social Work
21(2): 144–67.

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Family Matters: When Older Adults Are Caregivers

Volume 42 .Number 3 | 23

Older Adults, Caregiving, and
Late-Life Mental Health Issues
By Nancy P. Kropf

A trio of late-life mental health scenarios
demonstrate that families must seek to
understand and cope with their older
relatives’ mood and behavior changes.

abstract During later life, older adults may be caregiving for people with late-onset mental health
issues. The situation can alter family relationships and cause role transitions. This article offers three
late-life mental health scenarios that require spouses or partners, adult children, and-or others to deal
with an older adult family member’s mood and behavior changes. Through case examples, the author
explores geriatric depression, complicated grief, and provision of extended care for persons with severe
mental illness, and highlights support for older care providers. | key words: care provision, aging and
mental health, complicated grief, geriatric depression, aging and severe mental illness

Older adults become caregivers in later life for a variety of reasons, giving rise to role transi-
tions and altered family relationships. This article
offers three late-life mental health scenarios that
require spouses or partners, adult children, and-
or others in close relationships with an older adult
to deal with changes in mood and behavior. Two
of these conditions, geriatric depression (experi-
enced along with physical health conditions)
and complicated grief, typically arise during later
life. The third condition, severe mental illness,
emerges earlier in the life course, but includes
age-related changes, in both the care provider
and care recipient, which impact the caregiving
relationship.

For each condition, a brief summary of
the nature of the mental health condition is
described, as well as its impact on caregiving
and support relationships.

Specific changes, such as role transitions
and added care-provision responsibilities, are
highlighted and illustrated in an accompany –

ing case example (see the Author’s Note on
page 28).

Geriatric Depression
Physical and health changes that occur in later life
can be accompanied by comorbid psychosocial con-
ditions. In particular, patients who have had heart
attacks and strokes have high incidences of anxiety
and depression, post-event (Simning, Seplaki, and
Conwell, 2018). This is notable, as these two health
conditions are leading chronic conditions in adults
older than age 65 (Federal Interagency Forum on
Aging-Related Statistics, 2016).

In particular, a stroke often results in physi-
cal changes that require rehabilitation to restore
functioning. In a meta-analysis on research about
depression and stroke, Ayerbe et al. (2013) reported
that 55 percent of post-stroke patients experienced
depression during recovery. A predictor of depres-
sion is disability status, especially paresis (mus-
cular weakness) and incontinence, and resulting
functional limitations (Ayis et al., 2016).

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G E N E R AT IO N S – Journal of the American Society on Aging

24 | Fall 2018

For care providers, this experience can result
in multiple care-related outcomes. One is assum-
ing new tasks that were previously performed by
the patient—such as an older woman becoming
the primary driver after her husband’s stroke.
Another is when providers must undertake
care-related tasks such as assisting the patient
with activities of daily living. Due to the rate of
depression among stroke survivors, caregivers
also may deal with clinical symptoms that can
compromise patients’ abilities to regain degrees
of functioning. As a result, caregivers need to
adjust to physical, emotional, and social changes
after such an acute physical event. If the patient
does not regain previous levels of functioning,
numerous transitions may result that impact
relationship dynamics.

Case example No. 1
The following case example involves an older
couple after the husband sustains a serious
stroke. This scenario highlights how the wife
must take on new roles in caring for the husband,
as well as manage the household—and changes
in the family system.

Arthur and Melinda Pembroke are an Afri-
can American couple in their late sixties. Arthur
worked in the post office for forty years and
retired about four years ago. Two years ago,
Arthur suffered a significant stroke, and spent
time in a long-term-care rehabilitation facility
prior to returning home.

Arthur has experienced substantial changes
in his physical and social condition. A proud
man, he had handled many household responsi-
bilities such as driving, paying the bills, and tak-
ing care of the lawn. In his retirement, he had
started doing most of the cooking, as he always
enjoyed being in the kitchen. His three adult
children and their families often would come
over for barbecues, which he enjoyed very much.

Post-stroke, Arthur had difficulty with ambu-
lation and experienced muscle weakness. He was
unable to drive, had to use a walker, and also was
incontinent. A slight woman, Melinda had a dif-

ficult time assisting Arthur, who was tall and
overweight. Also, she was unprepared to take
over the many household tasks, especially driv-
ing, as she had never been comfortable in this
role. Arthur’s jovial personality changed, and he
became sullen, withdrawn, and disengaged.

Because of these multiple changes, the cou-
ple became reclusive. For the most part, they
stopped leaving their home and declined offers
to socialize—even from their children, who
invited them to their homes. Their house, always
a source of pride, fell into disrepair. Although
their adult children offered help, Melinda was
unwilling to accept aid and Arthur was adamant
that he did not want “strangers” in his house
(e.g., home health aides, a homemaker service).
Because of the couple’s physical status, combined
with a deteriorating physical environment, fam-
ily members became concerned about Arthur’s
and Melinda’s overall health.

This case example illustrates the intersection
between physical and mental health functioning.
Although Melinda is determined to provide care
for her husband, the associated tasks appear to
be beyond her capacity, and Arthur’s decreased
functional ability changed his personality, which
compromised his convalescence and recovery.
Although the family is willing to help, the couple
becomes more isolated and is reluctant to receive
aid and support.

Currently, the Pembrokes have not made use
of services that could provide support and relief.
An initial concern for professionals in aging ser-
vices who would serve these clients is how to
ensure the family accesses available services, as
Melinda and Arthur have become isolated and
estranged from their social network. Because
Arthur does not want “strangers” in his house,
one possibility is support offered through their

‘Patients who have had heart attacks
and strokes have high incidences of
anxiety and depression, post-event.’

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Volume 42 .Number 3 | 25

faith community. Examples of programs that
are provided through places of worship include
respite and friendly visiting. Likewise, Arthur
may be open to exploring an adult day or senior
center where he could participate in activities
and make social connections. This option would
offer respite for Melinda, as well as allow Arthur
to establish relationships with other individuals
who are in similar life circumstances, and who
can help with adaptation and acceptance.

Likewise, others in the Pembroke family
would benefit from resources. Melinda and her
adult children have limited understanding of
the consequences of a stroke and the ways to
provide care for Arthur. Additionally, they could
use support to help them meet Arthur’s physi-
cal challenges and also to know how to pro-
cess the emotional aspects of care provision.
(The National Stroke Association, along with
other healthcare organizations, offers sev-
eral resources [tinyurl.com/yc86ydzp]). While
Arthur would benefit from programs to help
him adapt to his post-stroke functional abilities,
the family also can use support and re sources to
adjust to his physical and emotional changes.

Complicated Grief
Besides the occurrence of changes in physical
and functional status, losses happen in later life.
Loss is a normal part of the life course and, in
later life, older adults experience the death of
significant individuals in their lives. Many older
adults are able to cope with these losses, how-
ever, others may experience complicated grief,
which is a prolonged and acute experience that
extends for a significant amount of time (Ghes-
quiere, 2014). Complicated grief involves intense
sorrow and emotional pain regarding the death,
and preoccupation with the deceased or the cir –

cumstances of the death. One estimate is that
4.7 percent of the older population suffers from
complicated grief; risk factors for complicated
grief include losing a spouse or a child, having a
cognitive impairment, and possessing a low level
of education (Newson et al., 2011).

Most often, those who have experienced a
loss do not receive therapeutic interventions for
their grief (Benkel, Wijk, and Molander, 2009).
Instead of abating, their grieving may worsen
over time. One person reported her family’s
impatience with her after a person extremely
important to her died. They said, “You should
be feeling better now . . . . You should be moving
on. You need to get out. You need to do this, you
need to do that” (Ghesquiere, 2014).

As caregivers and other support profession-
als are involved with older adults’ grieving expe-
riences, they may adhere to a different trajectory
around mourning. Thus, they may be less able—
or willing—to engage with bereaved individuals
over an extended period of time (Logan, Thorn-
ton, and Breen, 2018). Consequently, family and
friends experience a double loss—of the individ-
ual who died, and also of their former relation-
ship with the grieving person in their care, who
now may be disengaged or isolated.

Case example No. 2
The following case concerns an older widow,
Alma, who experienced the death of her young-
est son, Joseph.

After the death of her husband (seven years
prior to her son’s death), Alma had moved into
the household of her oldest daughter Frances,
age 62. Although she grieved for her husband,
Alma’s large family was instrumental in keeping
her active and engaged. After the untimely and
sudden death of her son, however, Alma’s health
started to decline as she become more with-
drawn and inactive.

Joseph, age 46, had worked as a long distance
trucker. He had never married, and re mained
close to his mother, who was age 82 when he
died. Although he lived across town and was on

Melinda is determined to assume care
of her husband, but the tasks are
beyond her capacity.

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26 | Fall 2018

the road a great deal, he and his mother spoke
several times a week and he would take her out
to dinner when he was not working.

Joseph was found dead in his rig at a truck
stop, and his autopsy revealed an undiagnosed
cardiac condition. While it was a shock to the
entire family, Alma was devastated. When
Joseph died, her behavior was radically differ-
ent than it had been when her husband had
died. Over time, she became more isolated from
her children and grandchildren. After coming
home from work, Frances frequently would
find her mother on her bed, tearful and disen-
gaged. Though Alma was devout, she stopped
attending mass at the local parish church, as
she said, “God should have taken me—not
Joseph.” She discontinued activities such as
taking daily walks, listening to music, and
connecting with her grandchildren. Her phy-
sical appearance changed—she looked frail
and unsteady.

Apart from Joseph’s death, the family expe-
rienced other losses. Besides Joseph’s sudden
passing, they no longer had their mother and
grandmother as part of their family life. Impor-
tant rituals such as Sunday night family din-
ners ceased. The entire family, and especially
Frances, felt helpless to assist their mother, who
seemed to be unable to get past her loss, instead
becoming increasingly frail and disengaged.

In this case example, the loss of an impor-
tant role for Alma—her close relationship with
Joseph—had a deleterious impact on her health
and social functioning. Alma’s remaining adult
children, having sustained the loss of a sibling,
felt helpless as they experienced an additional
loss of the “mother that they knew.” Seeing
Frances as Alma’s main source of support, the
siblings looked to her to help their mother cope
with the loss of Joseph. Previously a close-knit
family, Joseph’s death started to strain existing
familial relationships.

This example demonstrates several complex
dimensions of care provision. Although there
was no physical caregiving element in Alma and

Joseph’s relationship, clearly there was a strong
emotional bond. Joseph was a source of connec-
tion and companionship when Alma became a
widow. In contrast, daughter Frances, the pri-
mary source of Alma’s care, is herself enter-
ing later life. Along with dealing with the loss of
her younger brother, she now has an increased
responsibility for her mother, who is emotionally
devastated by Joseph’s death.

At this point, Alma clearly should have treat-
ment and support for her grief. There are effec-
tive intervention models for complicated grief
(see Nam, 2017; Shear et al., 2014), however,
older adults may resist seeking professional
help. Often, declining health is noted in primary
healthcare practices, and these health profes-
sionals should screen for depression and assist
with treatment referrals. Frances would benefit
from support from other care providers who are
dealing with these issues. Involvement in a fam-
ily support group could help Frances and her
siblings work through their grieving over the
loss of their brother, and bolster their efforts to
care for Alma.

Severe Mental Illness
Caring for someone with severe mental illness
(SMI) is a complicated situation. SMI is defined
as mental illness that results in a “serious func-
tional impairment that substantially interferes
with one or more major life activities” (National
Survey on Drug Use and Health, 2012). Examples
of psychiatric conditions that are classified as
severe mental illnesses include bipolar disorder,
schizophrenia, major recurrent depressive disor-
der, and personality disorders. Many people with
SMI exhibit erratic and unpredictable behavior,
hallucinations, and poor judgment, which can
leave their families especially unprepared for
this caregiving role (Jönsson et al., 2011).

As individuals with SMI age, care provid-
ers frequently are family members, such as older
parents and siblings. Estimates suggest that
about 85 percent of aging adults with SMI are
living in community-based settings, with about

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Volume 42 .Number 3 | 27

Phillip’s parents live in fear of his
having another psychotic, possibly
violent, episode.

50 percent living with family (Cohen and Ibra-
him, 2012). This caregiving role may be even
more difficult for families if relationships within
the family group have been severed, as behaviors
associated with SMI can create strain. Unfor-
tunately, many communities lack comprehen-
sive services and supports for people with SMI;
this leaves caregivers with insufficient resources
to meet the multiple and complex needs of this
population (Band-Winterstein, Smeloy, and
Avieli, 2014; Cummings and Kropf, 2009). Com-
munity supports that provide assistance to older
family caregivers include employment and activ-
ity programs for the person with SMI, respite
and residential options, and community health
programs that focus on the critical needs experi-
enced by later-life caregivers.

Because of their own aging process, older par-
ents who remain as caregivers to an adult son or
daughter aging with SMI face challenges in their
role. As the course of the mental illness changes,
care provision needs also evolve, requiring new
skills plus an understanding of the particular
care that is needed (Möller-Leimkühler and
Wiesheu, 2012), which can include management
of “negative psychiatric symptoms” such as leth-
argy, depression, withdrawal, and cognitive slow-
ing—symptoms that often are more difficult for
older parents to handle (Cummings and Kropf,
2011). Due to the simultaneous aging process of
both care receiver and caregiver, older care pro-
viders may have less capacity for assuming more
demanding caregiving tasks, while their adult
child with SMI requires additional assistance
(Cummings and MacNeil, 2008).

Case example No. 3
The following case scenario exemplifies the care
transitions that can occur in this caregiving situ-
ation (Greene and Kropf, 2014).

Phillip Bowman, age 40, was diagnosed with
schizophrenia in his early twenties. He lives at
home with his 75-year-old parents, William and
Claudia. Although he has had numerous psychi-
atric hospitalizations, Phillip has been at home

for the past two years. Currently, he has a flat
affect, hallucinations involving religious and
sexual themes, and mild paranoid ideation.

Due to Phillip’s illness, William retired early
to be a full-time caregiver, providing the major-
ity of care because Claudia has her own health
problems. The cumulative stress of caregiving
has isolated them from their friends, commu-
nity, and their other son’s family. William
is very concerned about potential danger for
Claudia, as she has osteoporosis and is quite
frail. A few years ago, Phillip pushed Claudia
down, resulting in a fall that broke her arm.
Phillip’s parents live in fear of his having

another psychotic episode, in which he could
exhibit violent behavior.

Despite the challenges, the family is very
religious and the parents view Phillip’s care as
their responsibility. But there are few psychiatric
resources in the community—especially for indi-
viduals who are in mid-life. Added to the ongo-
ing stress of his care, William and Claudia worry
about Phillip’s future when they can no longer
care for him.

In this caregiving situation, older parents
have been in a care provision role for their adult
son. However, the intersection of Phillip’s,
William’s, and Claudia’s aging processes cre –
ates new risks around the caregiving role, and
the lack of in-community services for people
aging with SMI causes a gap in support at a time
when this family needs additional resources
and support.

This case also exemplifies the need for future
planning, as Phillip may outlive his parents.
Another article in this issue of Generations (see
VanderVeen’s article on page 104) explores the
issue of financial and estate planning, which is crit-
ical in situations such as this one. The Bowmans—

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28 | Fall 2018

and other families in similar situations—should
seek assistance from attorneys who have knowl-
edge and expertise in this area; these professionals
can help families to make financial decisions that
can safeguard their adult children’s futures. They
also can identify any appropriate resources for
other needs families may have in later life.

Conclusion
In a typical caregiving pattern, an older adult is
the care recipient. The three scenarios in this
article offer examples of situations in which
older adults are the caregivers. When late-life
physical health challenges arise for these care-
givers, such as the occurrence of a stroke, geri-
atric depression can be a comorbid condition
that can complicate their ability to provide care.
In addition, complicated grief or bereavement
can compromise an older adult’s functioning
and create strain within the caregiving relation-
ship. The final situation presented, of an older
adult child aging with a severe mental illness,
juxtaposes the aging process of the care recipi-
ent with the older parents’ diminished ability to
sustain their caregiving role. Taken collectively,
these three scenarios offer a range of caregiving
situations that confront practitioners who are
dealing with issues specific to aging families.

As these cases show, the mental health is –
sues of late life affect family relationships and
dynamics. Even under the best of circumstances,
caregivers experience stress, struggles, and tran-
sitions (Feinberg and Levine, 2016). As a result,
the family system may benefit from becoming the
focus of treatment and interventions. As treat-
ment plans are made, practitioners and service
providers who are helping the caregiver may
also need to assess the care provider’s ability to
assume new care responsibilities, provide links
to appropriate services, and-or connect to oth-
ers who can be a source of mutual aid and sup-
port. As they age, older adults may assume either
role—of care recipient or care provider—and
appropriate and relevant practice, policy, and
research must take this into account.

Nancy P. Kropf, M.S.W., Ph.D., is dean and professor in
the Byrdine F. Lewis College of Nursing and Health
Professions, at Georgia State University, in Atlanta,
Georgia. She can be contacted at nkropf@gsu.edu.

Author’s Note
The case examples used in this article are
blended, though realistic stories created to illus-
trate the narrative; they are not associated with
real-life individuals.

References
Ayerbe, L., et al. 2013. “The Natu-
ral History of Depression Up to 15
Years After Stroke: The South Lon-
don Stroke Register.” Stroke 44(4):
1105–10.

Ayis, S. A., et al. 2016. “The Nat-
ural History of Depression and
Trajectories of Symptoms Long
Term After Stroke: The Prospec-
tive South London Stroke Regis-
ter.” Journal of Affective Disorders
194(April): 65–71.

Band-Winterstein, T., Smeloy, Y.,
and Avieli, H. 2014. “Shared Real-
ity of the Abusive and the Vulner-
able: The Experience of Aging for
Parents Living with Abusive Adult
Children Coping with Mental Dis-
order.” International Psychogeriat-
rics 26(11): 1917–27.

Benkel, I., Wijk, H., and Molan-
der, U. 2009. “Family and Friends
Provide Most Social Support for
the Bereaved.” Palliative Medicine
23(2): 141–9.

Cohen, C. I., and Ibrahim, F. 2012.
“Serving Elders in the Public Sec-
tor.” In H. L. McQuiston et al., eds.,
Handbook of Community Psychia-
try. New York: Springer.

Cummings, S. M., and Kropf, N. P.
2009. “Formal and Informal Sup-
port for Older Adults with Severe
Mental Illness.” Aging & Mental
Health 13(4): 619–27.

Cummings, S. M., and Kropf, N. P.
2011. “Aging with a Severe Men-
tal Illness: Challenges and Treat-
ments.” Journal of Gerontological
Social Work 54(2): 175–88.

http://www.asaging.org/publications

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Volume 42 .Number 3 | 29

Cummings, S. M., and MacNeil,
G. 2008. “Caregivers of Older
Clients with Severe Mental Ill-
ness: Perceptions of Burdens and
Rewards.” Families in Society
89(1): 51−9.

Federal Interagency Forum on
Aging-Related Statistics. 2016.
Older Americans 2016: Key Indi-
cators of Well-Being. Washington,
DC: Federal Interagency Forum on
Aging-Related Statistics, U.S. Gov-
ernment Printing Office.

Feinberg, L. F., and Levine, C. 2016.
“Family Caregiving: Looking to the
Future.” Generations 39(4): 11–20.

Ghesquiere, A. 2014. “ ‘I Was Just
Trying to Stick It Out Until I Real-
ized that I Couldn’t’: A Phenome-
nological Investigation of Support-
seeking Among Older Adults with
Complicated Grief.” OMEGA—
Journal of Death and Dying 68(1):
1–22.

Greene, R. R., and Kropf, N. P.
2014. Caregiving and Care Sharing:
A Life Course Perspective. Wash-
ington, DC: NASW Press.

Jönsson, P. D., et al. 2011. “Experi-
ence of Living with a Family Mem-
ber with Bipolar Disorder.” Inter-
national Journal of Mental Health
Nursing 20(1): 29–37.

Logan, E. L., Thornton, J. A., and
Breen, L. J. 2018. “What Deter-
mines Supportive Behaviors Fol-
lowing Bereavement? A Systematic
Review and Call to Action.” Death
Studies 42(2): 104–14.

Möller-Leimkühler, A. M., and
Wiesheu, A. 2012. “Caregiver
Burden in Chronic Mental Ill-
ness: The Role of Patient and Care-
giver Characteristics.” European
Archives of Psychiatry and Clinical
Neuroscience 262(2): 157–66.

Nam, I. 2017. “Restoration-focused
Coping Reduces Complicated Grief
Among Older Adults: A Random-
ized Controlled Study.” The Euro-
pean Journal Of Psychiatry 31(3):
93–8.

National Survey on Drug Use and
Health. 2012. Physical Health Con-
ditions Among Adults with Men-
tal Illness. Washington, DC: U.S.
Department of Health & Human
Services, Substance Abuse and
Mental Health Services Adminis-
tration.

Newson, R. S., et al. 2011. “The
Prevalence and Characteristics
of Complicated Grief in Older
Adults.” Journal of Affective
Disorders 132(1): 231–8.

Shear, M. K., et al. 2014. “Treat-
ment of Complicated Grief in
Elderly Persons: A Randomized
Clinical Trial.” JAMA Psychiatry
71(11): 1287–95.

Simning, A., Seplaki, C. L., and
Conwell, Y. 2018. “The Association
of a Heart Attack or Stroke with
Depressive Symptoms Stratified by
the Presence of a Close Social Con-
tact: Findings from the National
Health and Aging Trends Study
Cohort.” International Journal of
Geriatric Psychiatry 33(1): 96–103.

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Reproduced with permission of copyright owner. Further
reproduction prohibited without permission.

Kropf, N. P. (2018). Older Adults, Caregiving, and Late-Life Mental Health Issues. Generations, 42(3), 23-29.

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Pachana, N. A. (2013). A Global Snapshot of Mental Health Issues, Services, and Policy. Generations, 37(1), 27-32. https://search-proquest-com.su.idm.oclc.org/docview/1415620468?accountid=87314

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