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Behavioral Health Across the Continuum of the Over-50 Divide

Few care managers have studied the continuum of care across the aging family. Gerontologists see the aging continuum as essentially half of our lives. Aging starts around 50, and these days it is not uncommon for people to live to be 100 or more. In a growing number of cases, half of our lifespan is spent growing old.

Yet individuals do not grow old in a vacuum. Family members age with them, effectually creating the continuum of the aging family. The less aged of this aging family is often referred to as the “young old,” which today includes the much-analyzed baby boomers but can range up to those as old as 85. This group is generally healthy yet tasked with care for the second group — the “old old,” or the frail elderly.

When over 85, elders routinely suffer the effects of chronic conditions. In fact as, Cathy Mullahy writes in a chapter on communication in Care Managers: Working With the Aging Family, a new book on geriatric care management, these frail elders are complex patients with several chronic conditions who see multiple treating physicians and take numerous medications. The continuum of care in the aging family involves the “young old” family caregivers trying to kick up their heels and have fun while often spending their retirement as unpaid caregivers to their elderly family members who may suffer complex health.

This continuum in the elderly family can be substantially affected by several behavioral health issues suffered by both generations — meaning that both the givers and the receivers of care, beginning as early as the 50s and 60s, are prone to disease states and afflictions that can include anger management, sexual dysfunction, memory loss and Alzheimer’s disease.

Not only do we see behavioral health issues across the continuum of the aging family, but as in all systems, the threads that connect the outer ends of the family are intertwined and interactive.

The family is a living, breathing system. It operates as all systems do. When one part changes — like an elderly parent needing care — then the entire system must change. Yet this can be problematic. Even with a plethora of “how-to” books on caring for an aging parent, the younger generation often fails to see this change coming. They may feel overcome by the stark and immediate family transition when an aging parent needs care and can no longer act as the titular head of the family. This shock originates in a basic premise that governs many systems: they hate to change.

When one part of a family breaks down, like an aging parent needing care, the system goes on red alert. Change is a dangerous life transition in the aging family, because the parts have to be reshuffled and the younger members must emerge to assume the former duties of their elders — in addition to caring for them.

AN INTERPOSITION TO THE CONTINUUM

Aging families can often utilize care management services to midwife them through this familial crisis, helping both the younger and older family members deal with behavioral issues like anger management, sexual dysfunction, memory loss and Alzheimer’s disease. In fostering help along these difficult transitions and fomenting a new sense of order, care managers can become critical engineers of repositioning across the entire family continuum. Let’s see how.

ANGER MANAGEMENT

Across the spectrum of the aging family, anger management is a major issue, especially for the younger generation. Look at it this way: the head of Medusa has many poisonous tendrils; elder abuse linked to caregiver stress in the “young old” caregiver is among the most deadly.

The needs of an older relative can be like a car crash. A care manager who uses a caregiver assessment — a new tool in the care manager’s toolbox — can detect signs of potential elder abuse and hear alarm bells signaling either physical or fiscal abuse. The blaring siren is the care provider suffering levels of clinical depression.

But research shows that the main root of elder abuse at the hands of a caregiver lies in past relationships between the giver and receiver of care. Again, this can be picked up by a caregiver assessment or in a psychosocial assessment or with a tool called a genogram.

A genogram, which maps family relationships, is an excellent assessment tool to find poor past caregiver-care receiver relationships, according to research published in the Handbook of Geriatric Care Management. A younger caregiver who had past quality relationships with the care receiver is less likely to experience caregiver stress and is less vulnerable to anger or violence. Care receivers and caregivers who had a violent relationship — distant parent-child acrimony, for example — are more likely to fall into the realm of potential physical elder abuse.

Conversely, there are warning signs in the care receiver that can predict abuse. A care manager can track these behaviors in a caregiver assessment. If a care receiver is verbally aggressive, calls the police or shows disruptive behavior or physical aggression, such behavior can indicate abuse as well. All of this can be tracked by a care manager’s caregiver assessment, psychosocial assessment or genogram. With these tools in hand, the care manager can work with the care provider to modify the caregiving situation.

SEXUAL DYSFUNCTION

When anger and sexual dysfunction merge it can result in a particular type of spousal abuse that inserts itself virulently into the aging family. Multiple chronic conditions in an elderly spouse, including dementia, can cause sexual aggression toward the caregiver spouse. Brain damage due to a stroke can lead to a loss of inhibition that presents with inappropriate sexual expression. Again, this can be assessed by a care manager through a psychosocial assessment, a caregiver assessment or anecdotal information gathered from a caregiver spouse.

The desire to continue sexual activity as we age is shown in a University of Chicago study that looked at both the younger and older generations in question. The study reveals that 73 percent of people from the ages of 57-64 had engaged in sexual activity during the previous year, along with, specifically, 26 percent of those from the ages of 75-85. We know, anecdotally as well, through relentless advertising for drugs aimed to treat sexual dysfunction, that older people are sexually active and are prone to sexual dysfunction issues.

The University of Chicago study revealed that half of those surveyed reported sexual problems. For men, the problem presents most often as erectile dysfunction; for women, it is vaginal dryness. Yet for all of these issues, just 22 percent of men and 38 percent of women discussed the problem with their doctors.

The geriatric care manager’s job includes detection of these sexual issues through assessment, supportive listening and referral to the older person’s physician for evaluation. It also might mean that the care manager accompany the client to the doctor’s office and help him or her discuss these very human, yet at times embarrassing, health problems.

MEMORY LOSS

Memory loss may confront both groups. In the younger generation, which may be playing the part of an overwhelmed caregiver, forgetfulness is one of the warning signs of caregiver burnout and stress. This, too, can be ascertained from a caregiver assessment. The younger generation, however, suffers actual dementia in significantly fewer numbers than their elders. By age 65, just 1-2 percent will suffer dementia, most of which is Alzheimer’s. But the number spikes ferociously, with 50-60 percent of all people over the age of 90 exhibiting symptoms of dementia, most of which is attributable to Alzheimer’s, according to researcher Peter Belson.

The “young-old” often move away from their families to retire in warm areas like Florida and Arizona. They settle in Sun City-like communities and, except for occasional visits, do not see their families on a regular basis. In addition, their adult children often move away from them as well, whether due to a job or marriage. This trend toward relocation has created formidable barriers in the aging family regarding the detection of memory loss, dementia and Alzheimer’s.

When families are separated, the early signs of memory loss in aging parents are often not detected by their distant adult children. Aging parents often hide their slow loss of mental functioning until a real crisis occurs — say, when they get lost while driving and end up in the local emergency room. At this point, the aging family’s younger members get a call from the hospital, rush in by expensive plane tickets, and the familial crisis explodes as the adult children and the healthy aging parent must face the stricken parent’s loss of independence. Many times, geriatric care managers are called in at this point of the crisis to assess the older person, hold a family meeting, arrange care through the family or paid caregivers, and begin to monitor the older person if the family lives at a long distance. The care manager may also introduce new technology to the older client and the family, like pill dispensers for those with memory loss, motion detectors to pick up wandering, or simple cell phones like Jittterbug for elders who find it difficult to recall phone numbers.

There are 70 different types of dementia. Alzheimer’s disease is the most common type and represents 60 percent of all dementia diagnoses. The care manager’s role in dementia or Alzheimer’s includes assessment with cognitive functioning instruments, functional assessments, with ADL’s and IADLs, caregiver assessment, and a genogram to map the family. The care manager can gather every family member’s point of view about the older person. They can support both generations of aging couples when one member has dementia or Alzheimer’s through care planning and ongoing care monitoring. This may lead to placement or higher levels of care in the home, which care managers can also deliver to the entire aging family.

Across the spectrum of the aging family, care management provides prodigious answers for behavioral problems — whether they are experienced by the young-old, the old-old or just the plain old.