When an Aging Loved One Resists Care

How many times has your mother refused to change her clothes? Has your father resisted getting out of bed? Has your wife pushed you away when you tried to brush her teeth? Many times a caregiver will be particularly frustrated by her loved one's refusal to help himself. At times she can't help but think that the person she cares for "36 hours a day" is going out of his way to make her miserable! The increasing irrationality of individuals with dementia makes it even harder on the caregiver.

Individuals who resist care and assistance are trying to communicate to you. If dementia, stroke, vision loss, hearing loss or other illness limits one's ability to speak and convey information effectively, body language and physical actions take on a greater role in communication. Refusal to accept care, physical contact or participation in an activity is the individual's way of telling you something.

When your loved one resists care, step back calmly and think:

Are there any environmental factors such as lighting, shadows, noise, commotion or other external influences that are causing the problem now? (Before you say something, think about what you are going to say. Check your emotions and frustration before you speak. Your increased frustration can contribute to your loved one's agitation. (Put yourself in her shoes. Use your knowledge of her personal background to pinpoint patterns and reasons for her reaction. (Is this confrontation worth escalating?

Choose your battles wisely. A head-to-toe bath is not necessary every day or even more than once each week. Similarly, clothes do not have to be changed every day if they are not soiled. (Refusal to accept care or engage in once-pleasurable activities is a sign that something is amiss. The caregiver can assess the situation for specific complicating factor and make adjustments if necessary: (Refusal to get out of bed: illness - Assess physical factors such as injury from a fall, bruises, temperature/fever, urinary tract infection, or oral infection.

Keep a thermometer handy and know how to use it. Make a point every day or so of inspecting skin for dryness, sores or bruises. Catching skin or mouth sores early on will limit long-term damage and illness. (Refusal to join family or participate in even small activities: environmental - Assess for too much noise, harsh lighting, or specific individuals who cause distress. Correct these distractions and integrate positive factors such as music, aroma, comfortable fabrics and warmer room temperatures.

Refusal to perform tasks and activities: depression - The inability to fully perform tasks for oneself can cause an individual to avoid those situations. Assist them as much as possible while encouraging them to do as much for themselves without embarrassment. This is time-consuming, but it is the best route for enhancing self-esteem and independence. (Refusal to take medication: physical side effects - Sometimes side effects result from medication that are unbearable to the recipient. Learn what possible side effects can occur from the drugs your loved one takes. Consult with the doctor to see if over-the-counter anti-nausea, anti-diarrhea, or anti-dizziness products can be taken with prescription medications.

Perhaps the medication can be taken at bedtime or mealtime to reduce side effects. When administering the medication, tell your loved one how it will help them and use distraction if side effects occur. (Refusal to bathe or change clothes: embarrassment - Limit other people's presence (even their voices), approach in a non-threatening way, undress/bathe one area at a time and keep the rest covered, speak calmly and tell your loved one what you are doing each step of the process. Talk about pleasant memories and stories as you are bathing/dressing. (Refusal to eat or clean teeth: illness, incapacity - Oral hygiene is essential for elderly persons since poor hygiene can make eating painful and compromise nutrition.

Don't let oral health get to a point where it is a problem. The sense of taste declines with age, so make efforts to improve the flavor of food, make it appear appetizing, and ensure that portions are of the right size and consistency. You may need to provide pre-cut portions or thickened liquids. See if better shaped utensils and plates help your loved one feed herself. (You may have to use your own creative ideas to get around resistance. One caregiver's mother often refused to settle down for dinner. So the caregiver helped her mother get dressed up a bit with a nice sweater, a brooch and her purse. The two dined out on the patio without incident.

If your loved one still resists care even after adjusting for other factors, remember that confronting your loved one at that time of heightened emotions may make both of you more agitated.

Dan Lynch is the President of Tender Hearts at Home, a Cincinnati, Ohio elder care company. Dan and his wife Jody found themselves in the challenging situation of caring for their ailing elder parents. Neither parent wanted to move to a nursing home, but Jody and Dan experienced difficulty in finding dependable in elder care. After falling in her home and remaining unfound for five hours, Jody's Father eventually transferred to a nursing home where his health steadily declined until his passing. This experience ultimately led Dan and Jody to form their company, Tender Hearts at Home, providing personalized senior care for the elderly and those in need who wish to remain independent in their own homes for as long as possible. Their company offers service in Cincinnati and Southwest Ohio in the counties of Warren, Butler, Hamilton, & Clermont.

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Mental Challenges That Seniors Face

The vast majority of older adults function very well in their later year but at the same time, some older adults develop mental challenges. I'm going to review the major mental health problems in this article that older adults may face, and what can be done to address those problems. I will also review the losses that can occur in later life and associated bereavement and grief.

Let's Start With The Symptoms of Depression.
Many people, including older adults, assume that it is reasonable to become depressed later in life. Since depression and emotional suffering are considered a part of later life, some mental health problems may be overlooked and not treated. Depression is not a normal part of aging. Results of a major epidemiological study (Weissman, Bruce, Leaf, Florio, & Holzer, 1991) indicate that fewer older adults (1-2%) meet the diagnostic criteria for a major depressive episode (MDE) than younger adults (3-4%). However, a larger proportion of older adults report clinically significant symptoms of depression that do not meet the diagnostic criteria for an MDE. Also, the rates of depressive symptoms are higher among older adults in inpatient medical centers and long-term care facilities than they are among seniors who live in retirement communities. Here is a list of symptoms used to diagnose MDE. These symptoms must be present for at least two weeks and impair normal daily functioning:

• Feeling sad, blue, or depressed or experiencing a loss of interest or enjoyment
  in life.



• At least four of the following symptoms:
  
  • - changes in appetite (may be accompanied by weight loss or gain)
  
  
  • - changes in sleep (too much or not enough)
  
  
  • - agitation or retardation of movement
  
  
  • - fatigue or decreased energy
  
  
  • - feeling worthless or guilty
  
  
  • - problems with attention and concentration or difficulty making decisions
  
  
  • - thoughts of suicide

It's important to note that to be considered part of depression, these symptoms cannot be the direct result of an organic factor like medication, medical illness, or an abused drug. They also cannot be part of usual bereavement after the loss of a love one.

Understanding the Difference between Depression & Dementia - The symptoms of depression and dementia can be very similar in a lot of ways. Both can cause:

• sleep disturbance



• loss of interest in pleasurable activities



• poor attention/concentration



• loss of appetite or unexpected weight loss



• agitation or retardation of movement



• irritability



• memory impairment

Some unique differences between depression and dementia are as follows:

• Depression is more identifiable by emotional symptoms like feelings of guilt or regret, thoughts of suicide or general loss of energy.



• Dementia symptoms are more physical like decreased language ability, difficulty organizing or losing things and in later stages, incontinence.

These are the challenges that mental health professionals face in determining whether an older adult is experiencing depression, dementia or both.

Dysthymia is a chronic, less severe form of depression. People with dysthmia experience depressed moods most of the time for at least two years. People often experience distress following an upsetting event. When the distress starts getting in the way of an individual's daily functioning, then he or she may be experiencing an adjustment disorder. Adjustment disorders occur within three months following a specific event and normally do not last longer than six months after the stressful event has ended.

Effective Treatment Comes In Three Basic Types - The basic types of treatment for depression are psychotherapy and antidepressant medication. Psychotherapy includes cognitive behavior therapy, interpersonal psychotherapy, and psychodynamic psychotherapy. Cognitive behavior therapy and interpersonal psychotherapy are both time-limited therapies.

Cognitive behavior therapy helps patients to understand the link between their thoughts, behaviours and emotions and to modify unhelpful thoughts and behaviors. Interpersonal psychotherapy focuses on depression's associated interpersonal factors, including grief, role transitions, interpersonal conflict and loss of interpersonal skills.

There are many medications available for treating depression. They are called Tricyclic antidepressants or TCAs and selective serotonin reuptake inhibitors or SSRIs. TCAs tend to have more side effects therefore clinicians usually prescribe SSRIs. Because older adults tend to metabolize medications more slowly than younger adults, these medications are started at lower doses and increased gradually to proper levels.

If you notice these symptoms in one or more of your parents or an elderly friend, encourage them to get help. A doctor who is experienced with geriatric medicine would be able to identify the symptoms and treat accordingly. Taking care of your health as you age is very important since health can greatly affect quality of life.

Identifying Bipolar Disorder and Mania - BIPOLAR DISORDER, formerly known as manic depression was named for the two emotional poles of the syndrome. Seniors with bipolar disorder cycle back and forth between periods of normal functioning and depression. Some people with bipolar disorder return to their normal level of functioning following an episode while others fall into major depression. The onset of bipolar usually comes when people are between 18 and 22 although it can appear later in life.

TREATMENT includes mood-stabilizing medications and psycotherapy may also be beneficial in helping people cope with the interpersonal and practical consequences of bipolar disorder.

MANIA - manic symptoms are rare among older adults who do not have a history of this disorder, however, most older adults can have manic symptoms as a result of medications, medical illness or drug abuse. Mania can be characterized by symptoms of extremely elevated or irritable mood swings, impairment in daily functioning or interpersonal relationships and at least 3 of the following symptoms:

• inflated self-esteem or feelings of invincibility



• decreased need for sleep



• extreme talkativeness



• racing thoughts or shifting ideas



• high distractibility



• increased level of activity



• engaging in behaviours with potentially serious consequences

Again, if you know someone who is displaying symptoms of bipolar disorder or mania, encourage them to see a qualified doctor. Most people can live normal lives with these disorders if treated.

Anxiety Disorders (Panic Attacks, Generalized Anxiety, Phobias, Obsessive-Compulsive Disorder, PTSD) - Anxiety is a normal response to stressful situations. Generally healthy older adults develop excellent skills for coping with this. Anxiety becomes a problem when it prevents an individual from engaging in normal activity or enjoying activities. It is very common for anxiety to accompany other psychiatric disorders, most notably depression.

PANIC ATTACKS are short periods (usually several minutes) of intense fear that come on unexpectedly. These periods are accompanied by symptoms such as heart palpitations, sweating, shortness of breath, nausea, chest pain, dizziness, shakiness, fear of losing control, going crazy, or dying. Some people experience panic attacks in response to certain situations while others experience them without any apparent trigger.

TREATMENT often includes a short-acting sedation medication and cognitive behavioral psychotherapy.

GENERALIZED ANXIETY DISORDER is commonly seen with older adults. As its name implies, people with GAD experience excessive worry or anxiety about multiple things, and it impairs their daily functioning. People with GAD experience at least three of the following symptoms: restlessness, problems concentrating, irritability, muscle tension, sleep problems, or premature fatigue. Sometimes the symptoms of GAD are directly due to a medical condition like thyroid, cardiovascular, respiratory, metabolic, or neurological disorders.

TREATMENT often includes a long-acting benzodiazepine and cognitive behavioral psychotherapy.

PHOBIAS are extreme fears of specific situations or objects. The most common phobia is agoraphobia, which is the fear of being in places where one cannot easily escape. This phobia makes it less likely that people will venture from their homes. Another phobia is social phobies which is extreme fear of social or performance situations in which a person may feel embarrassed. Social phobia is often experienced as public speaking anxiety. Other phobias are of animals, natural environments (such as heights, water), blood or needles, and certain situations like airplanes or enclosed spaces.

TREATMENT - cognitive behavioral therapy has been found to be helpful in treatment of phobias. The focus is primarily on teaching relaxation techniques and then exposing the person to the feared object or situation while relaxed.

OBSESSIVE-COMPULSIVE DISORDER or OCD is a disorder where people have recurrent obsessions or compulsions that are severe enough to impair their daily functioning. Common examples are obsessions with contamination (being infected with germs), doubts, or a need to have things in a certain order. Compulsions are repeated behaviors like hand washing, repeating a word to prevent someone from getting hurt, checking locks, cleaning. One compulsion that may be a problem in later life is hoarding things such as newspapers, clothes or other objects.

TREATMENT for this disorder should of course be conducted by licensed professional experienced with geriatric medicine.

PTSD or Posttraumatic Stress Disorder may develop after exposure to an extraordinarily stressful event, such as being threatened with death or personal harm or witnessing the death or severe injury of someone else. This disorder was first recognized in the United States after the Vietnam War. Most studies with this disorder have been conducted with war veterans, Holocaust survivors, and disaster victims. PTSD involves recurrent thoughts about or images of traumatic events, recurrent nightmares, feelings of reliving the event, or intense distress when reminded of the event. People with PTSD avoid thoughts about or people who were involved in the event, feel distant from others, have difficulty experiencing emotions, are very irritable, have trouble sleeping or concentrating, or are hyperaware of their surroundings. Often times, people attempt to medicate themselves with alcohol or drugs which definitely makes things worse.

TREATMENT for PTSD often includes anti-anxiety medications, antidepressant medications, and psychotherapy to minimize the impact of the traumatic event on the person's life.

PSYCHOTIC SYMPTOMS AND DISORDERS - Approximately 10 percent of older adults admitted to psychiatric hospitals report that psychotic symptoms began after the age of 65 (Webster &Grossberg, 1998). The most common causes for these symptoms are dementia, severe depression, and various medical problems such as infections or metabolic imbalances.

The Forms of Loss That Seniors Experience - Most literature on grief and loss focuses on bereavent after death of a loved one. While this focus is extremely important, there are many other losses that occur in later life.

PHYSICAL HEALTH - Normal aging involves loss of physical abilities such as hearing, vision, loss of muscle and bone mass, decreased sensitivity to touch, smell, and taste, decreased ability to heal from injuries and illnesses, slowed metabolism and loss of skin elasticity.

Later life may also be accompanied by chronic illness and disease for many such as cardiovascular problems, diabetes, osteoporoses, arthritis, cancer, chronic pain and kidney disease.

These illnesses and resulting disabilities can lead some older adults to stop participating in the things they enjoy doing including sports, gardening, housekeeping, cooking and attending social events. Once this happens, they are more likely to suffer from reduced cognitive functioning, loss of independence and loss of valued social role. For instance, a woman may think of herself as a mother, a wife, a community advocate or a friend. These roles provide meaning to her life and shape her sense of self-esteem. Once a person experiences this kind of role loss, it is important to replace it with another role of value otherwise, they are at risk for social isolation, depression and further decline.

WHAT CAN YOU DO? Remember that every person has inherent worth and something to offer. Don't be blinded to an individual's strengths in the face of loss. Consider, for example, a nursing home resident with multiple sclerosis who had become quadriplegic. Despite her physical loss, she was able to make audio recordings of her life story and favorite recipes to share with her children and grandchildren, thus leaving a legacy to her family. Explore each individual's remaining strengths. What are they good at? Capitalize on those strengths. Identify ways they can get involved in the community and help others. This gives their life meaning.

BEREAVEMENT AND GRIEF is the experience of the death of a loved one. Later life is accompanied by the loss of an increasing number of friends and family members. As people age, social networks shrink, leaving some older adults with fewer or no friends or family members. Some people learn to adapt but others who experience multiple losses are not able to cope as well. The effect of multiple losses may be overlooked by those around older adults and therefore, go untreated.

Loss of a spouse is tragic at any point in life, but the secondary losses (losses that occur as a result of the death) can be traumatic after 50 or 60 years of marriage. Not only has the individual lost a spouse, they have also lost their daily routine, companionship, valued social roles, and what some describe as "a large piece" of themselves. In short, some bereaved spouses feel as though they've lost their lives and their world as they knew it. These seniors are at great risk for social isolation and depression if they do not maintain their activity level and social interaction.

WHAT CAN YOU DO? Help your loved ones identify their individual strengths and the activities they enjoy. Help them find ways to engage in those activities to help them through the grieving process and to prevent emotional and physical decline. Be aware of your own attitudes toward dying, death and grief. Most people are very uncomfortable talking about death or listening to someone else talk about it. Grieving people often feel alone in their experience and do not want to burden others with talk of death. Giving a grieving person an opportunity to share personal feelings can be a very powerful experience.

Encourage the expression of feelings, needs and beliefs and listen closely to what is being expressed. Whether an individual is experiencing denial, anger, confusion, fear or guilt, you should remain calm, even when the emotions of the grieving person are intense.

Do not take anger or irrational outbursts personally. Remember, they are grieving. Because each person experiences grief very differently, do not tell a grieving person that you know what they are feeling or understand what they are going through. Instead, tell them you are sorry for their loss and offer your sympathy and support.

Never try to talk individuals out of their feelings. People experience intense emotions following a loss and need a safe place to express them. Use active listening skills, responding to statements without agreeing, challenging or disputing their perspective. Just listen carefully and acknowledge that you have heard what they said.

Allow the person time to think about their loss. This is especially important for older adults as they may be processing information more slowly.

Summary - Later life presents a host of challenges and losses but for the most part, older adults are able to deal with these challenges. A small portion of older adults will develop mental health problems such as the ones discussed in this article. It's important to understand the symptoms of these challenges and to know that there is help out there.

If you know someone or have a loved one who is suffering from any of these disorders, please encourage them to seek professional help so that they can lead a quality life.

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