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The Shift in the Aging Population By Kenisha Rotibi, LMSW

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1 The Shift in the Aging Population By Kenisha Rotibi, LMSW
GRIEF and LOSS The Shift in the Aging Population By Kenisha Rotibi, LMSW

2 Case Study Case Study: Mr. Scott is a 85 year old man who recently had a surgery at a local hospital. The surgery went well but as Mr. Scott was prepared to go home and take care of himself. He was notified that he will no longer be able to go home but instead he would be sent to a nursing home. While in the hospital Mr. Scott was placed on a psychiatric unit, after completion of several test. An Adult Protective Services (APS) report was filed and the state petition for Guardianship for Mr. Scott. He is now under stated custody and now is placed in the same nursing home with his wife of 57 years (Mrs. Scott was placed two weeks prior).

3 Loss Generally we think of loss and in relation to the death of someone. However loss comes in many forms. We are affected by and grieve the loss of anything that we value or are attached to i.e. Loss of health as we age, of our family home as it becomes too big for us or loss of ability (e.g. with a stroke). Older adults often have many major losses within a short period of time. For example, older adults who lose their spouses may suffer many losses, including financial security, their best friend, and their social contacts. The natural aging process brings many losses, such as loss of beauty and physical strength. Older adults may seem to overreact to a minor loss. What is considered a minor loss may bring memories and feelings about a previous greater loss.

4 Grief Grief is the inevitable process we experience as the result of a loss. Grief involves a series of stages including denial or disbelief, fear, anger, depression, and finally acceptance. These stages may overlap, or come in a different order. During this process we may experience myriad emotions, such as confusion, sadness, fear, guilt or hopelessness. These feelings will vary in intensity according to the size or extent of a given loss. Grieving after a loved one's death is known as bereavement. Not be aware that they are grieving. Older adults experience losses related to aging. They may need to give up roles within their family. They may lose physical strength and stamina. They may feel sad and experience other signs of grieving without knowing that they are grieving. Be unwilling to tell other people that they are grieving. They may also be unwilling to tell other people how sad they feel when they see or care for older loved ones who are ill or aging. Have long-term illnesses, including physical and mental disabilities, that interfere with their ability to grieve.

5 Common grief reactions
Anxiety and fear Sadness and loneliness Anger and shock  Hurt and guilt Relief and thankfulness   Low energy    Sleep disturbances Appetite disturbances Absentminded behavior    Poor concentration

6 Stages of Grief The Stages of Grief Denial, anger, bargaining, depression and acceptance The Kübler-Ross model continues to be widely used as a means for measuring one’s progress through the grief journey, a good foundation for those who are newly grieving and those who are encountering loss again. Universal Model that lets Social Workers know the stages of grief. We have the legendary Swiss psychiatrist Elisabeth Kübler-Ross to thank for outlining these stages of grief in her groundbreaking book On Death and Dying, which was published in 1969.

7 Symptoms of Grief and Grieving What does it look entail?
Grief is expressed physically, emotionally, socially, and spiritually. Physical expressions include crying and sighing, headaches, loss of appetite, difficulty sleeping, weakness, fatigue, feelings of heaviness, aches, pains, and other stress-related ailments. The stress of grieving may also weaken the immune system over time results in more frequent episodes of illness. For persons who have a chronic illness, grieving can exacerbate their condition. Emotional expressions include feelings of sadness and yearning as well as feelings of worry, anxiety, frustration, anger, and guilt All of these feelings are normal reactions to grief.

8 Symptoms of Grief and Grieving What does it look entail?
Social expressions include feeling detached from others, isolating oneself from social contact, and behaving in ways that are not normal for the individual. Spiritual expressions include questioning the reason for the loss, the purpose of pain and suffering, the purpose of life, and the meaning of death. After a death, one’s grieving process is influenced by how he or she views death. Lack the support system that they had in the past. Older adults who depended on their spouses or other family members for social contact may lack a support system after their spouses die or other family members move away or die. These older adults may feel lonely and think that they have no one to confide in.

9 Grief should not be confused with Depression
Roll coaster of Emotions Usually person is able to carry out activities obligations of daily living, after the first two or three weeks of grieving numbness, sadness, anger, guilt, anxiety, or fear, people may also find moments of relief, peace, or happiness. Feeling of Emptiness and Despair constant. Intense, pervasive sense of guilt. Thoughts of suicide or a preoccupation with dying. Feelings of hopelessness or worthlessness. Slow speech and body movements. Inability to function at work, home, and/or school. Seeing or hearing things that aren’t there. In addition, advancing age is often accompanied by loss of social support systems due to the death of a spouse or siblings, retirement, or relocation of residence. Because of changes in an elderly person's circumstances and the fact that elderly people are expected to slow down, doctors and family may miss the signs of depression. As a result, effective treatment often gets delayed, forcing many elderly people unnecessarily struggle with depression.

10 Obstacles in the process of Grieving for Aging Population
Obstacles that can develop from grieving include depression, anxiety, suicidal thoughts, and physical illness. These are the type of grief reactions that tend to require social work interventions Depression is the most common condition that can develop when a person is grieving. Depression is especially common in adults who experience a divorce or death of a spouse. It is also very common in relation to developing a chronic illness or disability in the Aging Population. Slide 9 or the involvement of other helping professionals, depending on the client’s preference).

11 Obstacles in the process of Grieving for Aging Population (cont.)
Anxiety also is common during the grieving process. However, anxiety can: Last longer than expected Become intense such that it interferes with functioning Include extreme guilt Such disruptive anxiety contributes to a more complicated grief response and can: Make people feel like they are losing control of their emotions. Overwhelming fear is also common. Trigger physical symptoms (anxiety attacks), which might be mistaken for a heart attack. Last point: During an anxiety attack, people are likely to have a feeling of intense fear or terror, difficulty breathing, chest pain or tightness, heartbeat changes, dizziness, sweating, and shaking.

12 Obstacles in the process of Grieving for Aging Population (cont.)
Some older adults may develop unresolved grief or complications associated with grieving. This may occur more often in older adults because they are more likely to experience: Many major losses within a short period of time. The death of their friends, including their spouses. Older adults who lose their spouses may suffer many losses, including financial security, their best friend, and their social contacts. Losses that occur as a part of the natural aging process, such as loss of beauty and physical strength. Loss of their independence or the development of illness and other conditions that are common in older adults. Anticipation of losing someone or something special to them.

13 Aging Population Statics
The older population--persons 65 years or older-- numbered 39.6 million in 2009 (the latest year for which data is available). They represented 12.9% of the U.S. population, about one in every eight Americans. By 2030, there will be about 72.1 million older persons, more than twice their number in People 65+ represented 12.4% of the population in the year but are expected to grow to be 19% of the population by Most disturbing among depression statistics is the fact that depression affects upwards of 50 percent of nursing home residents In the case of Mr. Smith he may have did better to get maybe 24hr care in his home instead of him having to go to nursering home which will ultimately had to his depression or loss

14 Aging Population Statics
When depression occurs in late life, it may be a relapse of an earlier depression. An estimated 6 percent of people ages 65 and older in a given year, or approximately 2 million individuals in this age group, have a diagnosable depressive illness If it is a first time occurrence, it may be triggered by another illness, hospitalization, or placement in a nursing home. Unlike the onset of depression in non-elderly populations, depression in the elderly is thought to be a psychological disorder triggered by specific stressors, such as medical illness. Another causal factor is grief following the death of a loved one.

15 DSM IV vs DSM 5

16 DSM IV vs DSM 5 Under the current DSM-IV criteria, the bereaved would have not qualified for depression unless symptoms persisted for longer than 2 months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. What criteria does a Elderly meet to have moved from Grief and Loss now to depression. It made sense to do this as most individuals successfully cope with the loss of a loved one without medical intervention, even though the first few weeks to months following a loss is associated with significant distress. True, the “old” DSM-IV criteria provided a mechanism to “override” the bereavement exclusion; for example, if the depressed, bereaved patient were psychotic, suicidal, preoccupied with feelings of worthlessness, or functioning very poorly in daily life. Unfortunately, there are many bereaved patients whose depressive symptoms are severe, but who would not “qualify” for the DSM-IV override criteria; for example, those with profoundly impaired concentration, significant weight loss, or severe insomnia. Under the DSM-IV “rules,” these bereaved patients probably would not have received a diagnosis of MDD and been provided appropriate treatment. True, the “old” DSM-IV criteria provided a mechanism to “override” the bereavement exclusion; for example, if the depressed, bereaved patient were psychotic, suicidal, preoccupied with feelings of worthlessness, or functioning very poorly in daily life.

17 What does the DSM 5 say about Grief and Loss
Bereavement Exclusion (why) there have never been any adequately-controlled, clinical studies showing that major depressive symptoms following bereavement differ in nature, course, or outcome from depression of equal severity in any other context—or from MDD appearing “out of the blue” major depression is a potentially lethal disorder, with an overall suicide rate of about 4%.3 Disqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks closing the door on potentially life-saving treatment. To be sure, ordinary grief is not a disorder, and does not require professional treatment--nor should any arbitrary time limit be placed on grief, whether after the death of a loved one or any other tragic loss - See more at:

18 Comprehensive geriatric assessment of psychosocial factors
Mini-Mental State Examination (MMSE)The Geriatric Depression Scale (GDS), The Montreal Cognitive Assessment (MoCA) and the Saint Louis University Mental Status (SLUMS) cognitive assessment tool are all in the public domain.

19 Mini–Mental State Examination
MSSE can no longer be used the risk of infringement is real. Photocopying or downloading the MMSE probably constitutes infringement. A licensed version of the MMSE can now be purchased from PAR for $1.23 per test. The MMSE form is gradually disappearing from textbooks, Web sites, and clinical tool kits

20 The Geriatric Depression Scale (GDS)
The GDS questions are answered "yes" or "no", instead of a five-category response set. This simplicity enables the scale to be used with ill or moderately cognitively impaired individuals. The scale is commonly used as a routine part of a comprehensive geriatric assessment. One point is assigned to each answer and the cumulative score is rated on a scoring grid. The grid sets a range of 0-9 as "normal", as "mildly depressed", and as "severely depressed". A diagnosis of clinical depression should not be based on GDS results alone. Although the test has well-established reliability and validity evaluated against other diagnostic criteria, responses should be considered along with results from a comprehensive diagnostic work-up.

21 The Geriatric Depression Scale (GDS)(Short Version)
No. Question Answer Score 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO Scoring: Assign one point for each of these answers: 1. NO 4. YES 7. NO 10. YES 13. NO 2. YES 5. NO 8. YES 11. NO 14. YES 3. YES 6. YES 9. YES 12. YES 15. YES A score of 0 to 5 is normal. A score above 5 suggests depression.

22 The Montreal Cognitive Assessment (MoCA)
The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Time to administer the MoCA is approximately 10 minutes. The total possible score is 30 points; a score of 26 or above is considered normal.

23 Saint Louis University Mental Status (SLUMS)
The SLUMS is a 30-point, 11 question screening questionnaire that tests orientation, memory, attention, and executive function, with items such as animal naming, digit span, figure recognition, clock drawing and size differentiation. The maximum score is 30 points, with the point values for correct answers written on the exam for easy scoring. Cut-off scores for dementia or mild neurocognitive impairment are based on the education level of the patient (high school and above or less than high school).

24 Social Worker Roles with the Aging Population

25 Social Work roles with the Aging Population
Clinical interventions – They may provide therapy for an elderly client who feels lonely or who is suffering depression or anxiety. Geriatric social workers encourage their clients to pursue stimulating activities, helping to arrange group outings. They can help clients cope with aging by recording “life stories” and help people say their goodbyes through writing letters, phone calls, videos, etc.

26 Social Work roles with the Aging Population (cont.)
Service interventions – Many social workers act as a link between their clients and the numerous public and private programs designed for the aging. Social workers help clients apply for appropriate services. They help sort out any problems in the delivery of these services.

27 Social Work roles with the Elderly Population (cont.)
Many geriatric social workers also offer counseling services, which often deal with end-of-life issues, bereavement, and other concerns common to senior citizens

28 Social Work roles with the Elderly Population (cont.)
To help older adults remain at home as long as possible, many geriatric social workers work within the home health care setting. These types of social workers often coordinate discharge planning from hospital to home and conduct home visits to ensure the client is safe, healthy, and thriving in their environment. They may help assess when home care is or is not appropriate for the client, help locate in-home assistance services, transportation services, Meal on Wheels, and recommend in-home care tracking technology. Geriatric social workers are trained to recognize normal and abnormal aging patterns. They can suggest when an elderly client needs to see a doctor and can arrange for a visit. With the help of geriatric social workers, some older adults may be able to live in their own home when they would otherwise need nursing home care If at all possible for Mr. Smith. The social worker would possible find

29 Healing Process (3 A’s) Awareness grants permission to acknowledge that indeed a loss has occurred. Acceptance of the loss provides a feeling of gratification, eliminating conflicting feelings that clash because the elder is unsure how to come to terms with the problem. Action allows the elder to move beyond the loss and replace it by putting something back into his/her life. By replacing the loss with something different can also help the elder reach a feeling of successful aging. For instance, the grieving widow may find solace by getting involved in a community program such as the senior center, engaging in activities that can enhance her life.

30 How to help the Aging Population deal with Grief and Loss
Giving the person time. Pointing out signs of sadness or changes in behavior. Spending time with the person Show you care!!!! *Giving an older person extra time shows that you are concerned and respectful of the person's needs. *This may help the person become aware of his or her feelings and may help the person feel more comfortable talking with you about how he or she feels.

31 How to help the Aging Population deal with Grief and Loss
Talking about the loss. Spending time with the person. Watching for signs of prolonged grieving or depression. An older adult who often seems to be alone can benefit from your company. Invite him or her to go for a walk or have a cup of coffee. Feelings of loneliness may last for a long time when an older adult has lost something or someone special, especially a spouse. Older adults often have more than one loss to deal with at a time. Talking about each separate loss may help identify the person's feelings. Separating losses from one another may also help the person feel less overwhelmed and more able to cope with emotional distress. Talking about the loss. Ask the person to talk about his or her loss. Older people, especially those who have experienced several losses over a short period of time, are often helped by sharing memories of the lost person. If you have concerns that an older adult is having difficulty working through his or her grieving, talk with a health professional.

32 Therapeutic Models and Intervention for Grief and Loss

33 Grief Counseling Grief counseling is short term and focuses on helping people work through the grieving process related to a major loss. Grief counseling is also called bereavement counseling, but the term "bereavement" usually is used only when referring to the loss of a person through death.

34 Grief Counseling (cont.)
Grief counseling typically has four components: Learning about grief and what to expect when grieving. In grief counseling, people are taught the normal grieving process, including expected feelings and thoughts. They are also taught how to tell the difference between normal grieving and other conditions, such as depression, that can develop from grieving. Expressing feelings. People are encouraged in grief counseling to express all their feelings, whatever they may be. Sometimes people who are having trouble expressing their feelings are encouraged to talk about their loss or to use other means of expressing themselves. For example, they may be asked to speak with the lost person as though he or she were there.

35 Grief Counseling (cont.)
Other coping strategies include. Writing Letters about their loss or writing to the lost person Looking at photos and remembering the lost loved one or object, or visiting the grave of a loved one who has died. Establishing new relationships. This component of grief counseling helps people develop a new relationship with the lost person or object. Since memories usually linger for years and can sometimes be troubling, emphasis is placed on learning how to incorporate memories of the past into the present.

36 Grief Counseling (cont.)
Developing a new identity. For example: A top corporate executive who retires strengthens his or her self-perception as a grandparent and spouse instead of as a corporate leader. A widow who has lost her husband of 45 years begins meeting with other women in her building for tea every morning. 4. Foot note: During grief counseling, people are taught how to develop a new sense of self after a loss.

37 References http://www.nejm.org/doi/full/10.1056/NEJMp1110652
does-geriatric-social-worker-do adults-who-are-grieving# bereavement-resource-guide/

38 References loss-of-bereavement.html disorder/bereavement-and-dsm-5-one-last-time Jones and Company Retrieved on 5/17/2014 l


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